Percutaneous dilatational tracheostomy: A prospective analysis among ICU patients

Introduction: Percutaneous dilatational tracheostomy (PDT) is a simple bedside procedure, particularly useful in the intensive care units. Over the last few decades, the technique of PDT has gained popularity due to its comparable safety to the more surgical tracheostomy (ST).

Objective: To describe the outcome of PDT using modified Ciaglia’s technique in patients of Surgical ICU.

Methodology: This was a prospective cohort study that analysed the outcomes of PDTs carried out on critically ill patients admitted in the surgical ICU, Pakistan Institute of Medical Sciences, Islamabad from August 2015 to January 2017. All PDTs were performed by the presiding consultant and his team using modified Ciaglia’s (Blue Rhino) technique. The main outcome was the frequency of perioperative and early complications within the first six days. Demographic variables and complications were recorded. Data was analysed using SPSS version 18.

Results: Seventy-four patients underwent PDTs in the surgical ICU with mean age of the patients was 49.17 ± 12.82 years. The commonest indication of tracheostomy was prolonged mechanical ventilation followed by failure to wean. Complications rate was 12.16% of which perioperative bleeding occurred in 6.7% of patients. Early complications within the first six days were wound infection, tube displacement and blocked tube.

Conclusion: PDT is a valuable, efficacious and safe method that can be performed at the bedside with minimal complication rate and needs to be considered more frequently in the intensive care units in developing countries.

Decortication as an Option for Empyema Thoracis

OBJECTIVE:To analyse the outcome and morbidity associated with decortication in empyema thoracis. STUDY DESIGN:A case series. PLACE AND DURATION OF STUDY:Departments of Surgery, Combined Military Hospitals (CMH) of Rawalpindi, Quetta and Lahore, from January 2006 to March 2018. METHODOLOGY:This is a retrospective study of 812 cases of open and VATS (video-assisted thoracic surgery) decortication for empyema thoracis, operated by the same consultants. Only patients with established empyema were included. Those who were unfit for one-lung ventilation, undergoing local anesthesia procedures like rib resection, clagget window or tube windows, with clotted hemothorax and malignant pathology were excluded. Posterolateral serratus sparing thoracotomy was used in open decortications. Multiportal or uniport VATS was employed for video-assisted thoracoscopic decortications (VATD). Histopathology and microbiological sampling was also done in all cases. RESULTS:There were 537 (66.1%) males and 275 (33.9%) females. Age ranged from 1 to 80 years with a mean of 37 years. Open decortication was done in 650 (80%), standard decortication with posterolateral thoracotomy in 458 (56.4%), minithoracotomy was done in 69 (8.4%) patients with loculated empyema, thoracotomy and open decortication with conventional thoracoplasty was done in 21 patients. Twenty-two patients required open decortications with tailored thoracoplasty and muscle flap. Open decortication with intercostal muscle (ICM) flap or primary closure of bronchopleural fistula was performed in 55 patients. VATD was done in 162 cases, out of which 120 were early empyema, and 42 were of chronic empyema; of which 22 required a further utility thoracotomy. Decortication with lung resection and muscle flap reinforcement to bronchial stump was done in 25 patients. Blood transfusion was required in 331 (40.7%). Twenty-six (3.4%) patients developed residual space and collection requiring intervention; and 384 (47.3%) patients had a histopathology diagnostic for tuberculosis. There were 11 (1.3%) deaths. CONCLUSION:Open decortication is still one of the preferred procedures in developing countries. VATD is also increasingly utilised for empyema.

Functional and clinical outcomes of open versus closed radius and ulna shaft fractures in adults: A prospective cohort study

Objective: To compare functional and clinical outcomes of open versus closed radius ulna shaft fractures in adults treated by internal fixation.

Methods: A prospective cohort study was conducted on patients presenting with traumatic radius and ulna shaft fractures to Aga Khan University and undergoing internal fixation between July 2015 to June 2019. Data was extracted from an ongoing orthopaedic trauma registry. Functional and clinical outcomes were assessed by Price et al. criteria at 6 weeks, 3, 6 and 12 months follow-up. Outcome scores of open versus closed fractures were compared.

Results: Twenty-nine adult patients with isolated radius and ulna shaft fracture were identified. Cause of injury was road traffic accident in 18 (62%) and fall in 11 (38%) patients. Seventeen (59%) were closed and 12 (41%) were open fractures. At 6week follow-up, better outcomes were observed in closed fracture group (p=0.01) with near-full range of motion and activity in 10(83%) patients as compared to 3(27%) in the open fracture group. No significant difference in outcomes was observed at 3 months and thereafter.

Conclusions: Earlier recovery of function at 6 weeks was observed in majority of patients in the closed fracture group. Our data shows that good-excellent functional and clinical results are achievable by internal fixation in both open as well as closed fractures of the shaft of radius and ulna in adults.

Sigmoid volvulus: a rare but unique complication of enteric fever

We present a case of sigmoid volvulus in a young male patient with culture-proven Salmonella Typhi in the blood which was sensitive to Meropenem and Azithromycin only, presented with fever, vomiting, loose stools, hematochezia, abdominal distention and tenderness with no signs of perforation on erect chest x-ray. Further, radiological imaging showed signs of sigmoid volvulus. An urgent colonic decompression with untwisting of the mesentery was performed. In our case, it can be said that sigmoid volvulus was developed as a complication of multiple drug-resistant strains of Salmonella Typhi. The resistance is acquired by alteration in the genome sequence. Currently, it is important to control such an unknown outbreak of multiple drug-resistant strains of Salmonella Typhi as it is a serious health care issue of disease control and prevention in Pakistan.

Pediatric Cataract Audit at a Tertiary Care Center in Karachi

Purpose: To perform pediatric cataract surgery audit at a tertiary care center in Karachi.

Study Design: Descriptive observational study.

Place and Duration of Study: From January, 2016 to July, 2018 at Ophthalmology Department of Jinnah Postgraduate Medical Center, Karachi.

Material and Methods: All patients with congenital cataract were included in study regardless of presence or absence of systemic association. Patients who were lost to follow up at three months were excluded from the study. Hospital records were reviewed retrospectively and data on patient demographics, preoperative presentations, intraoperative complications and postoperative visual outcomes was documented on predesigned proformas. All patients underwent lens aspiration, posterior capsulotomy and anterior vitrectomy. Surgeries were performed under general anesthesia. Preoperative and postoperative visual acuity was assessed with ability to fix and follow light/objects, Kay picture test and Snellen’s chart according to patient’s age.

Results: Three hundred and twenty six eyes underwent surgery for congenital cataract and sixty for traumatic cataract. Number of male patients was 54.93% and female was 45.07%. The average age of patients with congenital cataract was 5.01 years and that for traumatic cataract was 7.8 years. Amblyopia, nystagmus and strabismus were the commonest ocular comorbidities. Uncorrected visual acuity ranged from 6/18 to light perception preoperatively. Postoperatively 55% children with congenital cataract and 15% children with traumatic cataract had visual acuity better than 6/24.

Conclusion: Early surgery in congenital cataract gives good visual outcomes. In traumatic cataract extraction, the final visual outcome depends on other effects of trauma on ocular structures.

Role of Surgical Modality and Timing of Surgery as Clinical Outcome Predictors Following Acute Subdural Hematoma Evacuation

Background & objective
A Craniotomy (CO) or decompressive craniectomy (DC) are the two main surgical procedures employed for evacuation of acute traumatic subdural hematoma (ASDH). However, the optimal surgical procedure remains controversial. The beneficial effect of early surgical evacuation of acute subdural hematoma in improving outcome also remains unclear. Our objective was to study the role of these two parameters in determining the outcome in patients undergoing surgical evacuation of acute traumatic subdural hematoma.
A retrospective analysis of 58 patients presenting with acute traumatic subdural hematoma and with presenting Glasgow Coma Scale (GCS) ≤ 8 that had been operated in Lahore General Hospital between June 2014 and July 2015 was performed. The demographic data, preoperative GCS, type of surgical procedure performed and timing of surgery were analysed.
Forty (69%) patients underwent CO, and eighteen (31%) patients underwent DC. The CO and DC groups showed no difference in the demographic data and preoperative GCS. Six patients survived in the craniotomy group, while none survived in the decompressive craniectomy group (p=0.083). The relationship of timing of surgery with survival in the craniotomy group was found not to be clinically significant (p=0.87).
In this study craniotomy was associated with a better outcome as compared to decompressive craniectomy, however, the difference did not reach statistical significance. Early surgery was also found not to be associated with an improved outcome.

14 Years’ Experience of Esophageal Replacement Surgeries

Esophageal replacement is a challenge to the therapeutic skills of surgeons and a technically demanding operation in the pediatric age group. Various conduits and routes have been described in the literature, each with their specific advantages and disadvantages. We carried out this retrospective study to share our experience of esophageal replacement.

This study was conducted at the department of pediatric surgery The Children’s Hospital and The Institute of Child Health, Lahore. The records of patients treated for esophageal replacement were reviewed. The patients under follow-up were called for clinical evaluation and assessed of long terms complications if any.

A total of 93 patients with esophageal replacement were included in the study. Esophageal replacement was done with gastric transposition in 84 cases (90%), colon interposition in 7 cases (7.5%) including one case of redo colonic interposition, and jejunal interposition in 2 cases (2%). Routes of esophageal replacement were trans-hiatal in 71 (76%), retrosternal in 13 (14%), and trans-hiatal with thoracotomy in 9 (10%) patients. Postoperatively, all of the conduits maintained viability. Wound infection was seen in 10 (11%), wound dehiscence in 5 (5%), anastomotic leak in 9 (10%), anastomotic stenosis in 12 (13%), fistula formation in 4 (4%), aortic injury 1 (1%), dumping syndrome 8 (9%), reflux 18 (19%), dysphagia 15 (16%) and death occurred in 12 patients (13%).

There are problems with esophageal replacement in developing countries. In this context, gastric conduit appeared as the best conduit for esophageal replacement, using the trans-hiatal route for replacement, in the authors’ experience.

Changing face of trauma and surgical training in a developing country: A literature review

Trauma continues to be the major cause of disability and death globally and surgeons are often involved in immediate care. However there has been an exponential decrease in the number of the trained trauma surgeons. The purpose of the current review article is to summarize the published literature pertaining to trauma education in postgraduate surgical training programmes internationally and in a developing country as Pakistan. Several electronic databases like MEDLINE, PubMed, Google scholar and PakMediNet were searched using the keywords ‘trauma education’ or ‘trauma training’ AND ‘postgraduate medical education’, ‘surgery residency training’, ‘surgery residents’ and ‘surgeons’. The current training in most surgical residency programmes, locally and globally, is suboptimal. Change in trauma management protocols, and decrease in volume of trauma cases results in variable and/ or inadequate exposure and hands-on experience of the surgical trainees in operative and non-operative management of trauma. This warrants collaborative measures for integration of innovative educational interventions at all levels of the surgical educational programmes.

Rising trends in iatrogenic urogenital fistula: A new challenge

Objective: To analyze trends in iatrogenic urogenital fistula among patients admitted for fistula repair at the Pakistan Institute of Medical Sciences, Islamabad.

Methods: In this longitudinal study, all patients who presented for fistula repair between 2006 and 2018 were included in the study. Patient data were collected on age, parity, and type and etiology of fistula, which was classified as ischemic or iatrogenic.

Results: Of 634 fistula patients, 371 (58.5%) had iatrogenic fistula, while 263 (41.5%) patients developed ischemic fistula due to obstructed labor. Mean age of patients was 31.6 years. Yearly trends showed an increase in iatrogenic fistula from 43.2% in 2006-2008 to 71.4% in 2017-2018. The major etiological contributor to iatrogenic fistula was hysterectomy (52.5%), followed by cesarean hysterectomy (26.4%), and cesarean delivery (19.9%).

Conclusion: A rising trend in iatrogenic fistula was observed. This emphasizes the need for optimization of surgical approaches and surgical skills. Moreover, gynecologic surgeries should be restricted to authorized gynecologic surgeons.

Prevalence of Trachoma in Pakistan: Results of 42 Population-Based Prevalence Surveys from the Global Trachoma Mapping Project

Purpose: Previous phases of trachoma mapping in Pakistan completed baseline surveys in 38 districts. To help guide national trachoma elimination planning, we set out to estimate trachoma prevalence in 43 suspected-endemic evaluation units (EUs) of 15 further districts.

Methods: We planned a population-based trachoma prevalence survey in each EU. Two-stage cluster sampling was employed, using the systems and approaches of the Global Trachoma Mapping Project. In each EU, residents aged ≥1 year living in 30 households in each of 26 villages were invited to be examined by trained, certified trachoma graders. Questionnaires and direct observation were used to evaluate household-level access to water and sanitation.

Results: One EU was not completed due to insecurity. Of the remaining 42, three EUs had trichiasis prevalence estimates in ≥15-year-olds ≥0.2%, and six (different) EUs had prevalence estimates of trachomatous inflammation—follicular (TF) in 1–9-year-olds ≥5%; each EU requires trichiasis and TF prevalence estimates below these thresholds to achieve elimination of trachoma as a public health problem. All six EUs with TF prevalences ≥5% were in Khyber Pakhtunkhwa Province. Household-level access to improved sanitation ranged by EU from 6% to 100%. Household-level access to an improved source of water for face and hand washing ranged by EU from 37% to 100%.

Conclusion: Trachoma was a public health problem in 21% (9/42) of the EUs. Because the current outbreak of extremely drug-resistant typhoid in Pakistan limits domestic use of azithromycin mass drug administration, other interventions against active trachoma should be considered here.