Vascular injuries caused by tear gas shells: surgical challenge and outcome.

BACKGROUND: Tear gas shells are used to disperse the mob during any type of street protests. Vascular injuries due to tear gas shells have not been reported. The present study was undertaken to analyse the pattern, presentation, management and outcome of vascular injury due to tear gas shells. METHODS: Eighteen patients with vascular injury caused by tear gas shells from 1(st) Jan. 2008 to 31(st) Dec 2009 were studied. Patients with vascular injuries caused by causes other than tear gas shells were excluded from the study. RESULTS: All patients were treated with reverse saphenous vein graft as segmental loss was less than 2.5 cm. Wound infection was the most common complication, followed by graft occlusion. Amputation rate was 16.66%. Associated nerve injury occurred in 44.44% of the patients. CONCLUSION: Tear gas shell injuries should not be taken lightly. They can cause injuries as serious as vascular injuries. Vascular injuries cased by tear gas shells require prompt revascularisation to improve limb salvage. Despite proper revascularisation, patients have significant morbidity and need proper rehabilitation in the follow ups.

Missile vascular injuries: 19-year experience.

BACKGROUND: Missile vascular injuries have reached an epidemic proportion in Kashmir valley since the eruption of militancy. The present study was undertaken to analyze the mode, pattern, presentation, and management of missile vascular injuries. METHODS: A retrospective study of patients with missile vascular injury from January 1990 to October 2008 was undertaken. Five hundred eighty patients with missile vascular injury were studied. All patients with vascular injury due to causes other than missiles were excluded from the study. RESULTS: Most of the patients were treated by interpositional saphenous vein graft or end-to-end anastomosis. The most common complication was wound infection (22.7%) followed by graft occlusion (3.8%). The amputation rate was 3.3% and was higher in patients with a delay of >6 hours to revascularization and associated fractures. CONCLUSION: Missile vascular injury requires prompt resuscitation and revascularization. Preoperative angiography is seldom necessary. Doppler study may sometimes be needed to aid in the diagnosis.

Ascaris through a chest tube: a rare presentation.

A rare case of an Ascaris worm emerging through an intercostal chest tube is reported here because of its unusual presentation. A five-year-old male child had a liver abscess, which had ruptured into the right pleural cavity. An intercostal chest tube was inserted for right pleural effusion. On the 5th postoperative day, a 7 cm long worm was noticed emerging through the chest tube. Ascaris lumbricoides infestation can lead to serious complications because of the mobility of the worms. Though complications such as intestinal obstruction, volvulus, gangrene, pancreatitis, biliary obstruction, cholangiohepatitis, and liver abscess have been reported to occur, intrapleural ascariasis is an extremely rare situation. This report describes a clinical situation of intrapleural ascariasis and emphasizes the importance of remaining aware of this rare complication of ascariasis.

Efficacy and safety of beating heart mitral valve replacement.

BACKGROUND: The interest in beating heart surgery is growing since better results can be obtained with this procedure compared to conventional myocardial protection techniques using cardioplegic solutions. This led us to consider mitral valve replacement with beating heart. OBJECTIVES: This study aimed to determine the safety and efficacy of beating heart mitral valve replacement without cross clamp. METHODS: This prospective study was conducted on the patients with isolated mitral valve disease requiring mitral valve replacement according to ACC / AHA guidelines. In this study, 15 patients underwent mitral valve replacement using beating heart technique (Group A) and 15 ones underwent mitral valve replacement using arrested heart technique (Group B). The patients were randomized using block randomization. The data were analyzed using the SPSS statistical software. RESULTS: Preoperative parameters were comparable in the two groups. Most of the patients in both study groups were in NYHA class III or IV. Postoperatively, however, most of the patients in the two groups were either in NYHA class I or II. No mortality occurred in the beating heart group, while one mortality occurred in the arrested heart group. The results showed a significant difference between the two groups regarding the mean bypass time, mean operating time, mean ICU stay, and mean length of hospital stay. CONCLUSIONS: Beating heart mitral valve replacement is equally safe as the arrested heart technique. Thus, it is recommended as an appropriate alternative to the arrested heart technique for mitral valve replacement.

Evaluating peripheral vascular injuries: is color Doppler enough for diagnosis?

BACKGROUND: Vascular injury poses a serious threat to limb and life. Thus, diagnosis should be made immediately with minimally invasive methods. Doppler is a good aid in diagnosis of vascular injury. METHODS: The present prospective study was conducted on 150 patients who presented with soft signs (the signs which are suggestive but not confirmatory) of vascular injury. They were subjected to color Doppler examination before exploration. The patients with the features of vascular injury on color Doppler were subjected to exploration. On the other hand, those who had normal Doppler were subjected to CT- angiography. Then, the findings of the exploration were matched with those of color Doppler. The data were analyzed using the SPSS statistical software. RESULTS: Out of the 150 Doppler examinations, 110 (73.33%) were reported as positive, while 40 were reported as negative for vascular injury. These were subjected to CT-angiography and seven of them had the features of vascular injury on CT-angiography. All the patients with positive Doppler or CT angiography findings were subjected to exploration. Doppler had a sensitivity of 94% and specificity of 82.5% in diagnosis of vascular injury using Binary classification test. CONCLUSIONS: Color Doppler is an easily available, reliable, and handy method of diagnosing a vascular injury. It has a very high sensitivity and specificity in diagnosis of vascular injuries.

Wandering ascaris coming out through the abdominal wall.

A rare case of ascaris coming out through the anterior abdominal wall is reported here. A 40-year-old female had undergone dilatation and curettage by a quack. On the second day she presented with presented with features of peritonitis. She was explored. Resection anastomosis of the ileum was done for multiple perforations of the ileum. Patient developed a fistula in the anterior abdominal wall which was draining bile-colored fluid. On the 12(th) postoperative day a 10-cm-long worm was seen coming out through the fistulous tract which was found to be Ascaris lumbricoids. Ascaris lumbricoids can lead to many complications ranging from worm colic to intestinal obstruction, volvulus, peritonitis, pancreatitis, cholangiohepatitis, liver abscess and many more. Worm has been reported to come out through mouth, nostrils, abdominal drains, T-tubes etc. But ascaris coming out through the anterior abdominal wall is very rare hence reported here.

Evaluating conservative treatment for acute appendicitis with lump formation.

BACKGROUND: Interval appendectomy after acute appendicitis with lump formation (phlegmon) remains controversial. We conducted this study to determine the risk of recurrent appendicitis following initial non-operative treatment for appendicitis, and evaluate factors associated with recurrence. Secondarily, we evaluate the efficacy of interval appendectomy versus no appendectomy. MATERIALS AND METHODS: Patients who received conservative treatment for appendicitis with lump formation were prospectively studied from June 2006 to June 2008. These patients were followed for recurrence of appendicitis. RESULTS: Of 763 patients with acute appendicitis some 220 patients had lump formation (28.8%). Median age was 28 years. Conservative treatment was successful in 213 (96.8%) patients. The rate of recurrence was 13.1%, all occurring within six months after the index admission. Mean follow-up was 26±18 months. CONCLUSION: Conservative treatment of appendicitis with lump formation is efficient and the recurrence rate is low. Routine interval appendectomy after initial conservative treatment for lump formation is not a cost-effective intervention and not recommended.

Penetrating cardiac injury: a review.

Cardiac injury presents a great challenge to the emergency resident because these injuries require urgent intervention to prevent death. Sometimes serious cardiac injury may manifest only subtle or occult symptoms or signs. As there is an epidemic of cardiac injuries in Kashmir valley due to problems of law and order, we herein present a review on management of such injuries.

Ulcerative colitis: a challenge to surgeons.

Ulcerative colitis is a chronic disease that specifically affects the mucosa of the rectum and colon. Although the etiology of this recurring inflammatory disorder remains essentially unknown, there have been significant advances in identifying the likely genetic and environmental factors that contribute to its pathogenesis. The clinical course of the disease typically manifests with remissions and exacerbations characterized by rectal bleeding and diarrhea. Since ulcerative colitis most commonly affects patients in their youth or early middle age, the disease can have serious long-term local and systemic consequences. There is no specific medical therapy that is curative. Although medical therapy can ameliorate the inflammatory process and control most symptomatic flares, it provides no definitive treatment for the disease. Proctocolectomy or total removal of the colon and rectum provides the only complete cure; however, innovative surgical alternatives have eliminated the need for a permanent ileostomy. The aim of this review is to provide a detailed account of the surgical management of ulcerative colitis.

Brunner's gland hyperplasia: an unusual cause of gastrointestinal bleeding.

A case of Brunner's gland hyperplasia presenting as gastrointestinal bleeding is reported herein. A 40-year-old male presented to our hospital with features of upper gastrointestinal bleeding. The patient had a history of passing black tarry stools for the last two days. Upper gastrointestinal endoscopy was done, which showed a pedunculated polypoid lesion in the second part of the duodenum with active bleeding at the base of the polyp. Adrenaline was injected around the bleeding site; however, the patient continued to bleed. He was taken for surgery. A laparotomy was done, and the duodenum was mobilized and opened. A large pedunculated polyp measuring approximately 2 cm was found with bleeding at the base. Polypectomy was done. Histopathological examination of the specimen showed mature Brunner's gland with normal duodenal mucosa at the surface. Diagnosis of Brunner's gland hyperplasia was made. The patient is under follow-up and is symptom-free.

Crohn's disease: a surgeon's perspective.

Crohn's disease (CD) is known for wide anatomic distribution, different presentations, life-threatening complications, and multiple modalities of management. Its multiple implications are still unaddressed. Since all the patients do not show a good response to medical modalities of treatment, a significant percentage of these patients are referred to the surgeon for the palliation of complications or for the ultimate curative treatment. Since most surgeons come across such patients only rarely, it is sometimes difficult for them to choose the appropriate procedure at the time of need. Moreover, the various surgical modalities available for the different presentations and complications of the disease have not been adequately discussed. The aim of this review is to offer insight and a detailed account of the management of CD from a surgical perspective. This review offers an overview of the various surgical options available, their utility in context, and an approach to various scenarios of complicated CD.

Association of dyslipidaemia with cholilithiasis and effect of cholecystectomy on the same.

BACKGROUND: The association between gallstones and abnormal lipids and later increase in risk of coronary artery disease and stroke has been shown in many studies. The aim of study is to elucidate the association of dyslipidaemia with Cholilithiasis and effect of Cholecystectomy on the same. METHODS: 73 patients with symptomatic gallstones were studied prospectively. Plasma concentration of cholesterol, triglycerides, LDL, HDL was analysed preoperatively and postoperatively on day 3 and after 6 months of Cholecystectomy. None of the patients received any lipid lowering drug or dietary restriction. Results were analysed and compared. RESULTS: 36 (80%) of the female patients and 20 (71.42%) of male patients had one or other abnormality in their lipid profile preoperatively Plasma concentration of total cholesterol, triglycerides, and LDL cholesterol were significantly reduced in patients on day 3 of surgery and 6 months thereafter. There was no significant increase/decrease in HDL cholesterol in 6 months after Cholecystectomy. CONCLUSION: There was a significant decrease in plasma concentration of lipids in Cholecystectomy patients postoperatively. These changes in plasma lipids are likely to have significant effect in the development of coronary artery diseases in patients with Cholecystectomy.

Ascaris exit through the feeding jejunostomy tract: a rare case report.

A 65-year-old male was operated for esophageal carcinoma. Transhiatal esophagogastrectomy with jejunostomy feeding tube was done. Orals were started on the 12th postoperative day. The jejunostomy feeding tube was removed on the 20th postoperative day. Immediately after removal of the feeding tube, a 10-12 cm ascaris was seen emerging through the jejunostomy tract. Ascaris lumbricoides can cause a variety of complications like intestinal obstruction, perforation, biliary obstruction, pancreatitis, liver abscess, cholangiohepatitis, volvulus, and gangrene, etc. Although the above-mentioned complications have been frequently reported, ascaris exit through the feeding jejunostomy tract is very rare. This case is reported here to emphasize the importance of this complication of wandering ascariasis.

Reninoma presenting as cardiac syncope.

Reninoma, a renin-secreting tumor of the juxta-glomerular cells of the kidney, is a rare but surgically treatable cause of secondary hypertension in children. We report a case of reninoma presenting as cardiac syncope with long QTc on electrocardiogram due to hypokalemia.

Profile of missile-induced cardiovascular injuries in Kashmir, India.

BACKGROUND: Missile cardiovascular injuries have taken an epidemic proportion in Kashmir valley since the eruption of militancy in 1990. Present study was undertaken to analyse the pattern, presentation and management of missile cardiovascular injuries. PATIENTS AND METHODS: Three hundred and eighty-six patients with missile cardiovascular injuries since Jan 1996 to Oct 2008 were studied retrospectively. All patients of cardiovascular injuries due to causes other than missiles were excluded from the study. RESULTS: All patients of missile cardiac injuries were treated by primary cardiorrhaphy. Right ventricle was the most commonly affected chamber. Left anterior thoracotomy was most common approach used. Most of the patients of missile vascular group were treated by reverse saphenous vein graft or end-to-end anastomosis. Most common complication was wound infection (20.83%) followed by graft occlusion (1.94%) in missile vascular group. Amputation rate was 4.66%. Amputation rate was higher in patients with delay of >6 hours and associated fractures. CONCLUSION: Missile cardiac injuries should be operated early without wasting time for investigations. Clinical status at arrival, time interval till management, nature of injury and associated injuries, tell upon the mortality. Missile vascular injury needs prompt resuscitation and revascularization at the earliest. Time interval till revascularization and associated fractures has a bearing on mortality and morbidity.

Vascular injuries after bear attacks: Incidence, surgical challenges and outcome.

BACKGROUND: Bear mauling is rarely reported in medical literature due to its rare occurrence. Present study was undertaken to describe the pattern and management of bear maul vascular injuries in Kashmir. PATIENTS AND METHODS: Study of patients with bear maul vascular injury from 1(st) Jan 2004 to 31(st) Dec. 2008. Fifteen patients with bear maul vascular injury were studied. All patients of bear maul without vascular injury were excluded from the study. RESULTS: Most of the patients were treated by reverse saphenous vein graft or end to end anastomosis. Most common complication was wound infection (20%) followed by graft occlusion (13.33%). There was no operative death. CONCLUSION: Bear attacks are very common in Kashmir. Vascular injury due to bear maul needs prompt resuscitation and revascularization. Results are very good provided timely intervention for revascularization is done.

Evaluating a conservative approach to managing liver injuries in Kashmir, India.

AIM: There has been a steep rise in incidence of liver injury in the past few years because of increase in incidence of road traffic accidents. The aim of this study was to evaluate the role of non-operative management of liver injury due to blunt abdominal trauma. MATERIALS AND METHODS: All patients with liver injury from blunt trauma abdomen were studied between January 2000 and January 2010. A total of 152 patients with liver injury were put on conservative management. Hundred and three (67.77%) patients were males and 49 (32.23%) were females with an age range of 15-60 years (32.8 years). Most of the injuries were because of road traffic accidents (81.57%). Liver injuries were graded according to Moore's classification using computed tomography. Patients with Grade V and VI were excluded from the study. Patients who were unstable hemodynamically on admission were also excluded from the study. RESULTS: There was no mortality in our series. Eight patients needed exploration because they developed hemodynamic instability. Four of the patient developed post-operative liver abscess which was treated conservatively. CONCLUSION: Non-operative management of liver injury due to blunt trauma abdomen is a safe, effective and treatment modality of choice in hemodynamically stable Moore's grade I to Grade IV injury.

Feeding jejunostomy: does the benefit overweight the risk (a retrospective study from a single centre).

BACKGROUND: The purpose of this study was to review the efficacy and safety of feeding jejunostomy in terms of achieving the nutritional goals in patients undergoing esophagectomy for carcinoma of oesophagus and complications associated hence with. METHODS: A total of 463 patients underwent esophagogastrectomy for carcinoma oesophagus during this period. All these patients underwent Witzel feeding jejunostomy for post-operative enteral nutrition. Enteral feeding was started after 24 h of surgery and increased gradually till target caloric and protein value was achieved. Nutritional goals achieved were reviewed. All complications related to jejunostomy were recorded. RESULTS: The study comprised of 463 patients who underwent elective esophagogastrectomy. Mean age was 58 +/- 8.4 in male patients and 55 +/- 4.2 years in female patients. Patients spend a mean of 19 +/- 8.4 (range 10-49) days on jejunostomy feed. The targeted calorie requirement was achieved by post-operative day 3 in 408 (88.12%) patients. The catheter blockage was one of the main complications during the course of feeding. Seven patients required relaparotomy for catheter blockage. CONCLUSION: Feeding jejunostomy is an effective, safe, economic and well tolerated method of providing nutrition to the patients of esophagogastrectomy. Feeding jejunostomy should be done in every patient undergoing esophagectomy at the time of laparotomy.

Missile diaphragmatic injuries: kashmir experience.

BACKGROUND: Importance of repairing a diaphragmatic tear due to a missile injury cannot be overemphasized. Even a small diaphragmatic rent should be repaired because of morbidity and mortality caused by subsequent herniation and strangulation. METHODS: Fifty-three cases with diaphragmatic injuries caused by penetrating missiles were studied from January 1997 to January 2007. All the patients were primarily explored either for thoracic or abdominal penetrating trauma; the diaphragmatic injury was an associated incidental intraoperative finding. Thoracotomy was performed in 18 patients, Laprotomy in 33 patients and in two patients combined thorocoabdominal approach was utilised for managing associated visceral injuries. RESULTS: Overall mortality was 37.7%. Mortality was dependent on associated injuries of thoracic and abdominal viscera. Most patients died due to associated injuries and septicaemia. None of the patients had any sequelae of diaphragmatic repair. CONCLUSION: Immediate repair of diaphragmatic injury is of paramount importance to prevent subsequent complications of herniation and strangulation.