Reconstruction of soft tissue defects of hand: A systematic approach.

Background and Objective: A thorough insight into the management of hand injuries can shape the approach of a surgeon in order to achieve optimal outcomes for the patients. The aim of this study was to share our experience in reconstruction of the hand and establishing an algorithm for classification and treatment of hand injuries. Methods: This is a descriptive cross sectional study and was conducted from January 2020 to August 2022 at Burns and Plastic Surgery center, Peshawar. Data was collected from medical records about the patient demographics, mechanism of injury and type of procedures done. Defect size was classified into small (<5cm), medium (5cm to 10 cm) and large (>10cm). The defect site and size was cross tabulated against the method of soft tissue reconstruction in order to make the algorithm for reconstruction of hand injuries. Data was analyzed using SPSS. Results: The study population included 41 (75.9%) male and 13 (24.1%) female patients, mean age 31.56±14.1. Machine injuries (33.3%) and electric burns (24.1%) were the most common cause of hand soft tissue defects. The most commonly performed flap was Posterior introsseous artery (PIA) flap, followed by First dorsal metacarpal artery (FDMA) flap. Flap necrosis was observed in three cases (5.6%). Conclusion: This treatment algorithm for coverage of soft tissue defects in hand injuries will help with the decision making process of hand reconstruction and has didactic value for novice surgeons. It will also form the foundation for further work on this aspect of hand injuries.

Mulliken's Bilateral Cleft Lip Repair: Early Outcome Analysis.

OBJECTIVE: To determine the early surgical outcome of Mulliken's repair technique for bilateral cleft lip. STUDY DESIGN: Descriptive cross-sectional study. Place and Duration of the study: Burns and Plastic Surgery Centre, Hayatabad Medical Complex, Peshawar, Pakistan, from January 2020 to December 2021. METHODOLOGY: This study included 51 patients with bilateral cleft lip deformity. Patients were evaluated preoperatively to exclude any associated congenital anomalies or comorbidities. Then the patients were classified into mild, moderate, severe, and asymmetrical cases. Outcomes were determined immediately and one week postoperatively, as good (score 16-20), fair (score 11-15), and bad (0-10) on the basis of anthropometric measurements on outcome evaluation criteria (OEC). RESULTS: Preoperatively mild, moderate, and severe bilateral cleft lips were observed in 18 (35.3%), 6 (11.85%), and 15 (29.4%), respectively, while 10 (19.6%) were bilateral asymmetrical cleft lips. The postoperative outcome score ranged from 16 to 20 (mean 19.2+1.03) which falls in the good outcome range. Nasal symmetry was good in 64.7% (n=33) cases while 31.4% (n=16) patients had satisfactory scores. CONCLUSION: Although Mulliken's repair is by far the most prevalent type of repair for bilateral cleft lip patients, the results can vary markedly. The early outcome evaluation criteria is an objective tool to measure the outcomes. KEY WORDS: Cleft lip, Bilateral cleft lip, Mulliken, Mulliken's repair, Day care surgery, Outcome.

Soft tissue reconstruction of thumb: Classification of defects and standardization of treatment.

OBJECTIVE: The aim of this article is to share our experience of thumb defects based on the defect irrespective of the etiology of the defect and to work towards standardizing the treatment for thumb defects. METHODOLOGY: This study was conducted at the Burns and plastic surgery center at Hayatabad Medical complex from 2018 to 2021. Thumb defects were divided into small (< 3 cm), medium (4-8cm) and large defects (> 9cm). Post-operatively, patients were evaluated for complications. The type of flaps were stratified for size and site of the soft tissue defects to generate a standardized algorithm for thumb soft tissue reconstruction. RESULTS: After scrutinizing the data, 35 patients qualified for the study, including 71.4% (25) males and 28.6% (10) females. The mean age was 31.17+15.8SD. Right thumb was affected in majority of the study population (57.1%). Majority of the study population was affected by machine injury and post-traumatic contractures, affecting 25.7% (n=9) and 22.9% (n=8) respectively. First web-space and injuries distal to IPJ of thumb were the most common areas affected, accounting for 28.6% (n=10) each. First dorsal metacarpal artery flap was the most common flap followed by retrograde posterior interosseous artery flap, observed in 11 (31.4%) and 6 (17.1%) cases. The most common complication observed in the study population was flap congestion (n=2, 5.7%) with a complete flap loss in 1 patient (2.9%) cases. Based on the cross tabulation of flaps against the size and location of defects, an algorithm was developed to help standardize reconstruction of thumb defects. CONCLUSION: Thumb reconstruction is critical in restoring hand function of the patient. The structured approach towards these defects make their assessment and reconstruction easy especially for novice surgeons. This algorithm can further be extended to include defects of the hand irrespective of etiology. Most of these defects can be covered with local easy to do flaps without the need for a microvascular reconstruction.

Patients with small and diminutive proximal hyperplastic polyps have higher rates of synchronous advanced neoplasia compared with patients without serrated lesions.

BACKGROUND AND AIMS: The association of proximal small and diminutive hyperplastic polyps (HPs) with synchronous advanced neoplasia is not well-defined. However, sessile serrated polyps (SSPs), even when small, are known to portend a risk of synchronous neoplasia. Currently, the U.S. Multi-Society Task Force on Colorectal Cancer does not recommend a change in the surveillance interval when proximal small HPs are detected. We aimed to compare the rates of synchronous advanced neoplasia in a screening colonoscopy cohort of patients with small and then diminutive proximal HPs in comparison, first to a cohort absent any serrated or proximal HPs and then in comparison with a cohort with small proximal SSPs. METHODS: Consecutive screening colonoscopies were recorded between 2005 and 2010 at an academic medical center. Patients were divided into 3 mutually exclusive groups. Group 1 consisted of patients with at least 1 HP that was proximal to the sigmoid colon, <1 cm in endoscopic size, and up to 3 total HPs in number. Group 2 included patients without any proximal HPs or SSPs. Group 3 consisted of patients with 1 to 2 SSPs, with at least 1 being proximal to the sigmoid colon, that were <1 cm in endoscopic size and without dysplasia. Rates of synchronous advanced neoplasia in patients with small (<1 cm) and diminutive (≤5 mm) proximal HPs were compared with the rates for the other 2 groups. RESULTS: There were 482 of 2569 patients (18.8%) with a small proximal HP who met the criteria for Group 1. The rate of synchronous advanced neoplasia in patients with a small proximal HP (61/482, 12.7%) was significantly greater compared with the average risk in the non-serrated cohort (Group 2, 133/1878, 7.1%; P < .001). There was no significant difference in the rate of synchronous advanced neoplasia when the small proximal HP group was subdivided by size (≤5 mm, 51/404, 12.6% vs 6-9 mm, 10/78, 12.8%; P = 1.00). The rate of synchronous advanced neoplasia in patients with diminutive (≤5 mm) proximal HPs (51/404, 12.6%) was not significantly different from the rate observed with proximal SSPs of similar size (17/113, 15.0%; P = .529). CONCLUSION: Patients with small and diminutive proximal HPs tend to harbor higher rates of synchronous advanced neoplasia compared with those without any serrated lesions detected on screening colonoscopy. Surveillance outcomes for metachronous advanced neoplasia for patients with small proximal HPs deserves further study. The synchronous advanced neoplasia rate in patients with proximal diminutive HPs is similar to that of proximal diminutive SSPs and could have implications in a resect and discard strategy.

Prevalence of allergic rhinitis and asthma in patients with chronic rhinosinusitis and gastroesophageal reflux disease.

BACKGROUND: An association between chronic rhinosinusitis (CRS) and gastroesophageal reflux disease (GERD) has been previously reported; however, the underlying factors linking CRS and GERD remain to be elucidated. OBJECTIVE: To assess the association of GERD and CRS using prospective and retrospective approaches. METHODS: The retrospective study comprised a large cohort of CRS cases, whereas the prospective arm evaluated a series of CRS cases and controls. RESULTS: In the retrospective arm of the study, of the 1066 patients with CRS, 112 (10.5%) had GERD. Among patients with CRS, GERD was associated with higher body mass index, older age, and female sex. The odds ratios (ORs) for asthma and allergic rhinitis in the CRS group with GERD compared with the CRS group without GERD were 2.89 (95% confidence interval [CI], 1.905-4.389) and 2.021 (95% CI, 1.035-3.947). Furthermore, GERD was associated with a greater duration of CRS. Ninety patients with CRS and 81 controls were enrolled in the prospective arm of the study. In the CRS group, GERD was associated with asthma (OR, 4.77; 95% CI, 1.27-18.01). Patients with CRS and GERD had a longer duration and a younger age at onset of CRS. In controls, no association was found between GERD and asthma (OR, 0.67; 95% CI, 0.09-5.19) or allergic rhinitis (OR, 0.35; 95% CI, 0.05-2.59). CONCLUSION: Patients with CRS and GERD are more likely to have atopic conditions and asthma when compared with patients with CRS but without GERD. One of the potential explanations of this link is that comorbid GERD and atopic disease are potential risk factors for development of CRS.

Hypospadias repair: a single centre experience.

Objectives. To determine the demographics and analyze the management and factors influencing the postoperative complications of hypospadias repair. Settings. Hayatabad Medical Complex Peshawar, Pakistan, from January 2007 to December 2011. Material and Methods. All male patients presenting with hypospadias irrespective of their ages were included in the study. The data were acquired from the hospital's database and analyzed with Statistical Package for Social Sciences (SPSS). Results. A total of 428 patients with mean age of 8.12 ± 5.04 SD presented for hypospadias repair. Midpenile hypospadias were the most common. Chordee, meatal abnormalities, cryptorchidism, and inguinal hernias were observed in 74.3%, 9.6%, 2.8%, and 2.1% cases, respectively. Two-stage (Bracka) and TIP (tubularized incised urethral plate) repairs were performed in 76.2% and 20.8% of cases, respectively. The most common complications were edema and urethrocutaneous fistula (UCF). The complications were significantly lower in the hands of specialists than residents (P-value = 0.0086). The two-stage hypospadias repair resulted in higher complications frequency than single-stage repair (P value = 0.0001). Conclusion. Hypospadias surgery has a long learning curve because it requires a great deal of temperament, surgical skill and acquaintance with magnifications. Single-stage repair should be encouraged wherever applicable due to its lower postoperative complications.