Disaster management in combined military hospital Quetta

Objective: To review the mass casualty management at Combined Military Hospital Quetta [CMH QTA], from 2012 to 2015 and to recommend measures for enhancement of capabilities in order to handle major mass casualty events

Study Design: Descriptive, cross sectional

Place and Duration of Study: Combined military hospital Quetta, from Jan 2012 to Dec 2015

Material and Methods: This study is a review of the patients brought to CMH QTA, in different types of mass casualty events from 2012 to 2015. The type of trauma, the procedure carried out and the patient outcome in each case was recorded. The data were analyzed and based upon the mortality and morbidity of casualties, the evaluation of facilities available and required was carried out as per Joint Commission on Accreditation of Healthcare Organizations [JCAHO] standards

Results: Over a period of four years, out of 3507, the highest number of casualties [42%] were received in year 2013. Civilians represented the commonest victims [79%] followed by army personnel [13%] and frontier corps [8%]. The gunshot wounds and Improved Explosive Device [IED] blasts were on the top [53.5%] as a cause of mass casualty followed by road traffic accidents [37.5%]. The highest number of patients [89%] underwent minor procedures like debridement, stitching and aseptic dressing. Twenty five percent of patients required a team work of various surgical specialists

Conclusion: The existing resources are sufficient for managing minor and moderate mass casualty scenarios but proper planning and enhancement of resources [equipment, infrastructure and personnel] is essential to cope with any probable major mass casualty event. We recommend training of paramedical staff for receiving, triage, resuscitation and definitive management of casualties

Comparision of post operative chronic pain after excision of ilioinguinal nerve in lichtenstein's hernioplasty

Objective: To provide a comparative analysis of mean post-operative pain score after preservation and elective excision of ilioinguinal nerve [UN] using standard Lichtenstein hernia repair [LHR] technique

Study Design: Randomized controlled trial

Place and Duration of Study: Department of Surgery Combined Military Hospital [CMH] Rawalpindi/ Peshawar, from 15 May 2013 to 15 May 2014

Materials and Methods: One hundred and fifty patients with diagnosis of inguinal hernia satisfying inclusion/exclusion criteria were included. Patients were divided into two groups randomly. In group A, UN was carefully protected while excision were done in group B. Demographic as well as data concerning groin pain at 03 months post operatively were collected and analyzed using SPSS

Results: A total of 150 patients were included. Mean age in group A was 37.32 +/- 10.45 years while in group B was 36.56 +/- 10.26 years [p=0.653]. Majority of the patients in both groups were male [group A 89.33% [67], 92% [69] in group-B], while female constituted only minority [8 [10.67%] in group A and 6 [8%] group-B], the difference being statistically insignificant [p=0.571]. Majority of the patients had indirect hernia and mean operation time was similar in both groups. Mean postoperative pain score was 3.76 +/- 1.11 and 2.82 +/- 0.677 in group A and B respectively, the difference being statistically significant [p<0.001]

Conclusion: Mean post-operative pain score is higher in preservation techniques compared to elective excision of UN for the treatment of inguinal hernia

Pancreaticjejunostomy or pancreaticogastrostomy to prevent pancreatic fistula formation after pancreaticoduodenectomy

Objective: To compare the results of pancreaticogastrostomy [PJ] with pancreaticojejunostomy [PG] in preventing fistula formation after pancreaticoduonectomy [PD]

Study design: Quasi-experimental study

Place and Duration of Study: The study was carried out in Military and Combined Military Hospital Rawalpindi from August 2008 to March 2015

Material and methods: Patients of both gender aged 45-70 years with confirmed or suspected neoplasms of head of pancreas, periampullary or duodenal tumours were included. After pancreatico duodenectomy the pancreatic reconstruction was carried out either by pancreatico jejunostomy [duct to mucosa type, dunken in type] or double layer pancreatico gastrostmy.The fistula rate was recorded after both the procedures using the definition of International Study Group on Pancreatic Fistula

Results: During this study period, 30 patients underwent pancreaticoduodenectomy. In 21 [71.4%] patients pancreaticojejunostomy was done, [18 duct to mucosa type and three dunken type anastomosis] and in 9 [28.5%] patients pancreaticogastrostomy was carried out. Five [20%] patients [3 in duct to mucosa type and two in dunken type] in the pancreaticojejunostomy group developed pancreatic fistula [grade A=2, grade B=2 and grade C=1] and one patient [11.1%] in the pancreaticogastrostomy group developed postoperative pancreatic fistula [OR= 9.9, 95% CI: 1.06-92.7 p= 0.044]

Conclusion: In patients undergoing PD for pancreatic head, periampullary or duodenal tumours, PG is more effective than PJ in reducing the frequency of post-operative pancreatic fistula

Comparison of Negative Pressure Wound Therapy using Vacuum-Assisted Closure with Advanced Moist Wound Therapy in the treatment of Diabetic Foot Ulcers

Objective: To evaluate the clinical efficacy of Negative Pressure Wound Therapy [NPWT] using Vacuum Assisted Closure [VAC] compared with Advanced Moist Wound Therapy [AMWT] to treat Diabetic Foot Ulcer [DFU]

Study Design: Randomized control trial

Place and Duration of Study: Surgical Department, Combined Military Hospital [CMH] / Military Hospital [MH], Rawalpindi, from November 2010 to June 2012

Methodology: The study consisted of 278 patients, with 139 patients each in Group 'A' and 'B', who were subjected to AMWT and NPWT, respectively. Wound was assessed digitally every week for 2 weeks. Wound dimension and surface area were determined using University of Texas Health Centre at San Antonio [UTHCSA] image tool version 3.0. Efficacies of AMWT and NPWT were compared in terms of reduction in wound area over 2 weeks

Results: Mean age of presentation in group A was 55.88 +/- 10.97 years while in group B, it was 56.83 +/- 11.3 [p=0.48]. Mean duration of diabetes at presentation was 15.65 +/- 4.86 and 15.96 +/- 5.79 years in group A and B, respectively [p=0.74]. Majority of patients had Wagner's grade 2 ulcer [82% in group A and 87.8% in group B, p= 0.18]. Initial wound size in group A was 15.07 +/- 2.92 cm[2] and in group B 15.09 +/- 2.81 cm[2] [p = 0.95]. Wound size measured after 2 weeks, treatment was in group A 13.70 +/- 2.92 cm[2] and in group B 11.53 +/- 2.78 cm[2] [p < 0.001]. Wound area reduction in both groups revealed statistically significant faster healing in group B as compared to group A [p < 0.001]

Conclusion: NPWT using VAC was more efficacious than AMWT in the management of diabetic foot ulcers

Comparison of open cholecystectomy with laparoscopic cholecystectomy using latest variables of pulmonary functions as parameters

To compare open cholecystectomy with laparoscopic cholecystectomy using latest variables of pulmonary functions as parameters. Randomized controlled trial. Department of Surgery, CMH Rawalpindi from May 2010 to Nov 2010. Patients with symptomatic cholelithiasis subjected to elective cholecystectomy were studied. The patients were divided into two groups. Open Cholecystectomy was performed on patients in group I, and laparoscopic cholecystectomy was performed in patients in group 11. Respiratory function tests were performed preoperatively and on the morning of the 1st post-operative day. Preoperative pulmonary function tests were normal and did not differ significantly between the two groups. After operation a significant reduction in the FEVl [Forced Expiratory Volume in first second], FEV6 [Forced expiratory volume in first six seconds] and their ratio FEVl/FEV6 occurred after both open and laparoscopic cholecystectomy. However, mean reductions in FEV1, FEV6 and FEVl/FEV6 in the laparoscopic cholecystectomy group were significantly [p <0.05] less as compared with those after open cholecystectomy. Laparoscopic cholecystectomy causes less impairment of lung function than cholecystectomy performed through a subcostal incision

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

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