Outcomes of AV fistula formation for dialysis patients using interrupted sutures one-year single center study.

Objectives: To document the Outcomes of AV fistula formation for dialysis patients using interrupted sutures. Methods: In this Cross-sectional study conducted at PNS Shifa Karachi, from June 2022 to June 2023, patients above 18 years of age, male or female, with ESRD/CKD were included. After clinical screening and ultrasound doppler, the distal most part of wrist was considered as a site for radio cephalic AVF. Operation was performed under surgical loupe with 4.5x magnification. Standard incision of about 4-5 cm oblique proximal to the wrist crease was given at the volar surface on the radial side of Distal forearm, extending till the lateral side up to the snuffbox. Subcutaneous tissue was incised and dissection was done to identify the cephalic vein and radial artery. Distal most end of the cephalic vein was ligated using vicryl 4-0 suture and cephalic vein dissected free from the underling tissue to mobilize it up to the radial artery. Results: During the study N=35 patients who required AVF creation visited the department. The mean age of the study participants was 59.34±15.48. If thrill at the site of AVF and backflow at cut end of cephalic vein were present the surgeons were satisfied, higher satisfaction among the surgeon was achieved in the AVF created at brachiocephalic artery while the diameter of vessels didn't contribute in surgeon satisfaction. Conclusion: Presence of thrill at the site of AVF and backflow at cut end of cephalic vein have strong association with good prognosis of AVF.

The Outcome Of Pedicled Medial Sural Artery Perforating Flap For Proximal Leg Reconstruction.

BACKGROUND: Reconstruction of defects around the knee and proximal leg are difficult to reconstruct. Out of the multiple flaps described for reconstruction, the pedicled Medial Sural Artery Perforating Flap (MSAP) has recently gained popularity. We conducted this study to assess the clinical outcomes of pedicled MSAP for this purpose at our hospital. METHODS: A descriptive case series was conducted from April 2022 to March 2023. All patients above 18 years with defects around the knee and proximal leg were included. Patients with tissue loss in the calf area were excluded. RESULTS: A total of 14 patients were included. Twelve (86%) were males, while only 2 were females (14%). The mean age was 33.5 years (±8.76). The most common cause of the defect was trauma (n=11, 85%). The Mean distance of the distal-most perforator from the popliteal crease was 12.714 (±1.990) cm (range 9-16 cm). It was observed that the most distal perforator is usually present in a 2 cm radius of the medial musculo-tendinous junction of the gastrocnemius. Complications were seen in 2 (14%) patients. The mean duration of hospital stay was 4.2 (±0.96) days. Patients were followed up weekly for the first two weeks and then at 1, 3 and 6 months. CONCLUSIONS: MSAP Flap is a reliable thin, long pedicled fasciocutaneous flap with low donor site morbidity and aesthetically good results for reconstruction around the knee and proximal leg.

COVID 19 pandemic: Effect on management of patients with breast cancer; single center retrospective cohort study.

BACKGROUND: (SARS-COV-2) infection, led to a pandemic affecting many countries, resulting in hospitals diverting most of their resources to fight the pandemic. Breast cancer, already a healthcare dilemma, is also affected in this scenario. Our aim was to find out the impact of COVID-19 on presentation of breast cancer stage and its effects on overall onco-surgical management. METHODS: This cohort single-centered retrospective review was carried out at our hospital, over a period of 18 months. Females with known breast cancer were included in the study. Data was collected on performas by a single researcher. Effect of COVID pandemic on presentation stage and its impact on overall management was studied. SPSS 23.0 used for data analysis. A 95% CI was used. Descriptive statistics were presented as range/means. Categorical data was analyzed by Fisher exact test, t-test was applied to numerical data, p value ≤ 0.05 was considered significant. RESULTS: Out of 87 patients presenting with suspicious lump, 69 who had malignancy on histo-pathology were included in study. Twelve out of 69 were COVID positive. Sixty patients presented with advanced stage (≥stage 2b) out of which 21 underwent upstaging of disease due to delay in presentation/management. We found that 9 out of 12 (majority) Covid positive patients had disease upstaging. Overall main reason for delay in presentation was found to be unawareness of disease. CONCLUSION: We concluded that COVID-19 pandemic had no impact on presentation delay, breast cancer management/treatment and disease upstaging as compared to figures available for our population before the pandemic. However, our study showed significant correlation between disease upstaging and COVID status. This led us to reconsider our preformed protocols for COVID positive breast cancer patients. Our results can be used by future researchers to investigate if COVID itself can contributes in patho-physiology of upstaging in breast cancer or not.

THORACODORSAL ARTERY PERFORATOR FLAP FOR UPPER LIMB RECONSTRUCTION.

BACKGROUND: Thoracodorsal artery perforator flap (TAP) is a feasible option to reconstruct defects in upper limb where only skin and subcutaneous tissue is required. METHODS: This case series was carried out at department of Plastic and Reconstructive Surgery Combined Military Hospital Rawalpindi. A total of 5 patients with upper limb defects were reconstructed with thoracodorsal artery musculocutaneous perforator flaps. Among them, 3 were pedicled and two free TAP flaps. All flaps except one pedicled flap were raised on a single perforator pedicle. Recipient sites were one axilla, two shoulder regions and two hands. The soft tissue defects in the patients had resulted from burns, trauma, wide local excision of synovial sarcoma and surgery for hidradenitis suppurativa. Preoperative hand held Doppler ultrasound was used to locate and mark the perforator. RESULTS: All flaps survived without significant complications. All flaps were hyperemic in the immediate postoperative period. We designed and raised all the five flaps on eccentrically placed perforators. All the raised perforators originated from the descending branch of the thoracodorsal artery. The donor sites were closed primarily with linear scars in all cases except one, in which partial closure was accomplished with split thickness skin grafting (STSG). CONCLUSION: The thoracodorsal artery perforator flap has great potential for reconstructing large, relatively shallow, defects of upper limb because of its suitable skin quality, texture and appropriate thickness, as well as hidden donor site, a reliable pedicle and sparing of muscle unit.

Long-term morbidity of axillary lymph node dissection: implications for patients with carcinoma breast.

BACKGROUND: To assess the long term complications of level II Axillary Lymph Node Dissection (AXLND) in patients with breast cancer and to see if they are high enough to warrant a Sentinel Lymph Node (SLN) biopsy in all patients presenting with carcinoma breast in our setup in Pakistan. METHODS: This study was conducted at Surgical Unit IV, Department of Surgery, Combined Military Hospital, Rawalpindi. Upper, lower arm circumferences and body mass index were ascertained in post Modified Radical Mastectomy (MRM) with level II AXLND, in female patients who had undergone surgeries from 1992 to 2008. Patient's perception of degree of lymph oedema, arm function and other symptoms like pain, tingling and numbness was noted. The number of lymph nodes removed, number of positive nodes and post operative radiotherapy were also recorded from the hospital records. RESULTS: Thus upper arm circumference in 85.7% patients and lower arm circumference in 89.2% patients was within 2 Cm of the unaffected side. No, moderate and severe arm swelling was described by 83.35% of patients, 11.6% of patients and one patient respectively and 41.5% of patients describing some arm swelling had positive lymph nodes. Thus even if they had gone (SLN) biopsy, these patients would have had a subsequent AXLND. Over 94% of patients had either good or excellent arm function with most in the excellent range. CONCLUSION: The patients at significant risk for positive nodal may be better served with an AXLND rather than the SLN technique.