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.

The Efficacy of Rigid Bronchoscopy for Foreign Body Aspiration.

The aim of the current study was to determine the pattern, presentation and management of foreign body aspiration in our  population.  This prospective study comprised 55 patients with foreign body aspiration admitted to our department from January 2009 to December 2011. All patients underwent rigid bronchoscopy under local or general anesthesia. The patients' demographic information along with clinical characteristics and their outcome were recorded and reported. The mean age of the children was 13.3±3.6 years. There were 32 (58.2%) females and 23 (41.8%) males. The frequent symptom was an attack of chocking followed by cough. The predominant sign was wheezing. Rigid bronchoscopy was successful in removing foreign body from 52(94.5%) patients. Three (5.5%) patients who had undergone thoracotomy with bronchotomy needed exploration, after failure of bronchoscopy to remove the foreign body. There was no mortality in our series. Average hospital stay was 12 hours. It could be concluded that rigid bronchoscopy is modality of choice in management of foreign body aspiration especially in pediatric population.

Endorectal coil MRI and MR-spectroscopic imaging in patients with elevated serum prostate specific antigen with negative trus transrectal ultrasound guided biopsy.

BACKGROUND: The aim of this study was to see the efficacy of endorectal coil MRI and MR spectroscopic imaging in patients with elevated serum PSA and negative transrectal ultrasonography (TRUS)-guided biopsy. MATERIALS AND METHODS: This study was conducted on 87 patients presented with: • Elevated prostatic specific antigen levels >5 ng/ml • Symptoms and signs of prostatic carcinoma • Patients with negative TRUS-guided biopsy • Suspicious lesion on TRU. All the patients were subjected to TRUS and followed by TRUS-guided biopsy of the lesion identified on endorectal coil MRI and MR-Spectroscopy. TRUS-guided biopsy of prostate was done with a Siemens Sonoline Adana Scanner. The scanning was performed by mechanical probe 5-7.5 MHz. RESULTS: Out of 87 patients, 43 (49.4%) had hypointense lesion, 11 (12.6%) had hyperintense lesion. Out of 87 patients, MR-spectroscopy showed peak choline-creatine in 74 patients. Normal citrate peak was seen in 13 patients. Patients who had choline-creatine peak, among them 28 (37.8%) had peak in left peripheral zone, 23 (31.1%) had peak in the right peripheral zone, 2 (2.7%) had peak in the central zone, 17 had (23%) peak bilaterally. Four patients (5.4%) had peaks in right and central zones. The difference was statistically significant (P < 0.001). CONCLUSION: Prostatic biopsy directed with endorectal coil MRI and MR-spectroscopic imaging findings in patients with elevated serum PSA and prior negative biopsy, improves the early diagnosis of prostatic carcinoma and accurate localization of prostate cancer within the gland.

Esophageal Tuberculosis Presenting As Dysphagia.

Esophageal tuberculosis is rare in both immunocompromised and immunocompetent hosts with advanced pulmonary tuberculosis, even in countries with high prevalence of tuberculosis, e.g., South East Asia. This study presents a case report of esophageal tuberculosis presenting as dysphagia.

Lung Contusion: A Clinico-Pathological Entity with Unpredictable Clinical Course.

Lung contusion is an entity involving injury to the alveolar capillaries, without any tear or cut in the lung tissue. This results in accumulation of blood and other fluids within the lung tissue. The excess fluid interferes with gas exchange leading to hypoxia. The pathophysiology of lung contusion includes ventilation/perfusion mismatching, increased intrapulmonary shunting, increased lung water, segmental lung damage, and a loss of compliance. Clinically, patient's presents with hypoxiemia, hypercarbia and increase in laboured breathing. Patients are treated with supplemental oxygen and mechanical ventilation whenever indicated. Treatment is primarily supportive. Computed tomography (CT) is very sensitive for diagnosing pulmonary contusion. Pulmonary contusion occurs in 25-35% of all blunt chest traumas.

The Pattern, Presentation and Management of Pardah Pin Inhalation: Report from a Single Center in Northern India.

OBJECTIVE: To describe the clinical characteristics, presentation and management of Pardah pin inhalation in female teenagers of single center in northern India. METHODS: This was a prospective cross-sectional study being performed in department of cardiovascular and thoracic surgery of Sher-i-Kashmir institute of medical sciences located in northern India from January 2009 to December 2012. We included 36 female patients with Pardah pin inhalation who were admitted to our center during the study period. All patients underwent rigid bronchoscopy under local or general anesthesia. We recorded the baseline characteristics including the demographic information, the site of the pin and clinical findings as well as the management strategies and the outcome of these patients. RESULTS: All patients were female using scarf to wrap their head and neck as religious obligation. Mean age of the patients was 14.3 ± 3.6 years. The most common symptom was chocking followed by cough being reported in all (100%) and 31 (86.1%) patients respectively. Bronchoscopy was successful in removing the pin in 31 (86.1%) patients. Pins were located in right main bronchus in 20 (55.5%) patients, and in left main bronchus in 10 (27.7%) patients. There was no mortality in our series. Pin was removed in 31 (86.1%) patients with the help of bronchoscope, but 5 (13.9%) patients needed bronchotomy for removal of the pin. Average hospital stay was 12.43 ± 1.6 hours. CONCLUSION: Rigid bronchoscopy is an ideal approach in management of Pardah pin inhalation. However some patients may need bronchotomy to remove the Pardah pin.

Comparison of right anterolateral thorocotomy with standard median steronotomy for mitral valve replacement.

OBEJECTIVES: The objectives of this study were to compare and analyze the results of right anterolateral thoracotomy and median sternotomy approach for primary mitral valve replacement with reference to the exposure during Valve Replacement , length of surgical incision, mean cross clamp time, mean bypass time, intensive care unit (ICU) stay, hospitalization, overall comorbidity with sternotomy; sepsis, dehiscence, healing cosmetic issues and cost effectiveness. METHODS: The present study comprised 68 patients with rheumatic mitral valve disease who underwent mitral valve replacement in the Department ofCardiovascular and Thoracic Surgery at Sher­i­Kashmir Institute of Medical Sciences from September 2009 to August 2011. RESULTS: This study comprised 64 patients with 23 (35.9%) males and 41 (64.1%) females. Sternotomy group had 10 males (31.3%) and 22 females (68.7%). Thoracotomy group had 13 males (40.6%) and 19(59.4%) females. The length of incision between the two groups was statistically significant (P<0.0001). Mean incision length were 24.6±2.1 cm and 14.8±2.3 cm in sternotomy and thoracotomy respectively. Statistically significant difference regarding duration of ICU stay was found between the two groups (P<0.0001). Scar visibility was 100% in sternotomy and around 25% in thoracotomy( P<0.0001). CONCLUSIONS: Thoracotomy through a right anterolateral aspect was easy to perform while maintaining maximum security for the patients. Besides its satisfactory cosmetic result especially in female patients, this approach proved to have several advantages. It offers a better exposure to the mitral apparatus even in patients with small left, allowing easy mitral valve replacement which is apparent from the lower cross­clamp time in the test group. The invaluable advantage of the above- mentioned thoracotomy is total eradication of the risk of deep sternal infection. The shorter hospital stay and cost effectiveness of thoracotomy approach are additional relief to the family.

Peripheral vascular injuries due to blunt trauma (road traffic accident): management and outcome.

BACKGROUND: The present study was undertaken to analyze the pattern, presentation and management of peripheral vascular injuries due to road traffic accidents (RTA). METHODS: A prospective study of patients of peripheral vascular injuries due to road traffic accidents (RTA) between Jan. 2007 to Dec. 2011. A total of 192 patients presented with peripheral vascular injuries due to RTA during this period. All patients with vascular injury due to other causes were excluded from study. RESULTS: Most of the patients were managed by reverse saphenous vein graft followed by end to end anastomosis. Most of the patients had associated long bone fractures. Delayed presentation and associated long bone fractures had bad effect on outcome. Wound infection and thrombosis of the graft were the most important complication. Amputation rate was 4.68%. CONCLUSION: Vascular injury due to RTA requires prompt recognition and referral to a vascular center. Immediate revascularization has excellent results and less morbidity. Proper clinical examination and hand held Doppler examination are enough to reach the diagnosis.

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.

Vascular injuries: trends in management.

ABSTRACT: Vascular injury presents a great challenge to the emergency resident because these injuries require urgent intervention to prevent loss of life or limb. Sometimes serious vascular injury presents with only subtle or occult signs or symptoms. The patient may present weeks or months after initial injury with symptoms of vascular insufficiency, embolization, pseudoaneurysm, arteriovenous fistula etc. Although the majority of vascular injuries are caused by penetrating trauma from gunshot wounds, stabbing or blast injury, the possibility of vascular injury needs to be considered in patients presenting with displaced long bone fractures, crush injury, prolonged immobilization in a fixed position by tight casts or bandages and various invasive procedures. iatrogenic vascular injuries constitute about 10% of cases in most series; however the incidence is an increasing trend because more endovascular procedures such as angioplasty and cardiac catheterization are being performed routinely. Civilian trauma is more frequently seen in young males. However, it can occur at any age due to road accidents, firearms, bomb blasts and diagnostic procedures. Most of the time, civilian trauma causes less tissue damage. There is an epidemic of vascular injuries in Kashmir valley because of problems in law and order in the past two decades. This review deals with the topic in detail.

Role of liberal primary fasciotomy in traumatic vascular injury.

BACKGROUND: Vascular injury represents less than 1% of all injuries, but deserves special attention because of its severe complications. Amputation or retention of a painful functionless limb is the most untoward result of severe vascular injury or inadequate treatmet. Thus, vascular injury needs a judicious and multidimensional approach. OBJECTIVES: This retrospective study was done to asess the outcome of minor modifications of the methodology of extremity fasciotomy by making it liberal with respect to incision and definition. MATERIALS AND METHODS: Out of 55 patients in 2008, 45 patients (Group A) had either no fasciotomy or limited primary fasciotomy, 10 patients (Group B) had primary liberal fasciotomy. Another group from 2008 onwards had undergone primary liberal fasciotomy in all the 45 patients (Group C). RESULTS: In group A, we had 5 amputations and one death. In group B, there were no amputations or deaths and from group C, we had one amputation and no deaths. CONCLUSIONS: Blunt and distal traumatic vascular injury of the extremities and its repair should always combined with primary liberal fasciotomy, which although increases manageable morbidity, avoids disability (functional as well as anatomical).

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.

Primary pelvic hydatid cyst: a case report.

This is a case report of a young man who presented to us as a case of hypogastric pain and frequency of micturation. General physical examination and radiological evaluation confirmed a multiloculated pelvic swelling. Patient was subjected to laparotomy which confirmed the diagnosis of a primary pelvic hydatid disease. Patient was put on chemotherapy after surgery and is doing well on follow up.

Laparoscopic and open incisional hernia repair using polypropylene mesh - a comparative single centre study.

INTRODUCTION: Repair of incisional hernias continues to be a challenging surgical procedure for general surgeons. Currently open mesh repair and laparoscopic repair are the two main options available for general surgeon for managing this complication. Laparoscopic repair though offers all the advantages of minimal access surgery but is a costly procedure especially due to the use of costly composite mesh. The present study is aimed to compare the open and laparoscopic repair of incisional hernia and at the same time evaluate the safety and feasibility of using comparatively cheaper polypropylene mesh. METHODS: Between December 2005 and December 2009 80 patients underwent incisional hernia repair, 40 open repairs and 40 laparoscopic repair. The results of the two procedures were compared with a mean follow up of 26 months for open repair and 28 months for laparoscopic repair. RESULTS: Obstetrical or gynecological procedure was the most common index surgery leading to incisional hernia and lower midline incision was the most common site of hernia. The mean defect size in open repair group was 55.2 cm(2) and 62.2 cm(2) in laparoscopic repair group. Polypropylene mesh was used in all cases. We had 1(2.5%) major complication of enterotomy and 1(2.5%) conversion in laparoscopic repair group. Postoperative complications were most commonly seen in open repair group 10(25%) and 2(5%) in laparoscopic repair group. Mean hospital stay in open repair group is 4.33 days and 1.53 days in laparoscopic repair group. We had 1(2.5%) recurrence in both groups. CONCLUSION: Laparoscopic repair of incisional hernia is a much better procedure for curing incisional hernia as compared to open mesh repair and additionally intraperitoneal use of polypropylene mesh was not associated with any significant complication.