Irfan Qadir

Emergency incisional hernia repair: a difficult problem waiting for a solution

BackgroundEmergency repair of incarcerated incisional hernia with associated bowel obstruction in potentially or contaminated field is technically challenging due to edematous, inflamed and friable tissues with occasional need for concurrent bowel resection and carries high rates of post-operative infectious complications. The aim of this study was to retrospectively assess the wound related morbidity of use of permanent prosthetic mesh in emergency repair of incarcerated incisional hernia with associated bowel obstruction. We also describe a new technique of leaving the mesh exposed to heal by secondary intention with granulation tissue.MethodsBetween 2000 and 2010 a total of 60 patients underwent emergency surgery for incarcerated incisional hernia with associated bowel obstruction with placement of permanent prosthetic mesh. The wound was closed after hernia repair in 55 patients while it was left open to granulate in 5 patients.ResultsIn the group of patients with primary wound closure, 11 patients developed superficial surgical site infection, 5 developed deep wound infection and one patient had cellulitis. These patients were treated with wound debridement and antibiotics. Mesh removal was required in one patient. There were no infections in the group of patients who had their surgical wounds left open. One patient in this group died on the fifth postoperative day from septicemia.ConclusionUse of permanent prosthetic mesh in emergency repair of incarcerated incisional hernia with associated bowel obstruction. in contaminated field is associated with high risk of wound infection.

Predictors of length of hospital stay after total hip replacement

Purpose. To identify variables affecting length of hospital stay after total hip replacement (THR) while controlling for potential confounders. Methods. Records of 199 consecutive elective unilateral THRs were reviewed. Clinical and demographic data including age, gender, body mass index, comorbidities, surgical factors (surgical approach, type of prosthesis, use of cement, operating time), anaesthetic factors (type of anaesthesia, ASA physical status), and length of hospital stay were recorded. Results. 64% of patients left hospital within 12 days, 28% within 3 weeks, and 8% after 3 weeks. The median length of hospital stay was longer in women than men (11.5 vs. 9 days, p=0.009), in patients aged >65 years than those younger (13 vs. 9 days, p<0.0001), and in those with American Society of Anesthesiologists (ASA) grades 3 and 4 than grades 1 or 2 (14 vs. 9 days, p<0.0001). A greater proportion of women than men (45% vs. 27%, p=0.007), patients aged >65 years than those younger (61% vs. 37% or 24%, p<0.0001), and those with ASA grades 3 and 4 than grades 1 and 2 (68% vs. 25%, p<0.0001) stayed 12 days or longer. In the multiple regression analysis, the predictors for prolonged hospital stay (≥12 days) were patient age >65 years (p<0.003), female gender (p<0.05), and ASA grades 3 and 4 (p<0.0001). Of the 72 patients with prolonged stay, 7% had no, 26% had one, 42% had 2, and 25% had all 3 predictors. Conclusion. Prolonged hospital stay after THR is largely predetermined by case mix. Our study helps to identify individuals who need longer rehabilitation and more care.

Subacromial impingement syndrome

Subacromial impingement syndrome (SAIS) represents a spectrum of pathology ranging from subacromial bursitis to rotator cuff tendinopathy and full-thickness rotator cuff tears. The relationship between subacromial impingement and rotator cuff disease in the etiology of rotator cuff injury is a matter of debate. However, the etiology is multi-factorial, and it has been attributed to both extrinsic and intrinsic mechanisms. Management includes physical therapy, injections, and, for some patients, surgery. No high-quality randomized controlled trials are available so far to provide possible evidence for differences in outcome of different treatment strategies. There remains a need for high-quality clinical research on the diagnosis and treatment of SAIS.

Impact of Unplanned Excision on Prognosis of Patients with Extremity Soft Tissue Sarcoma

Unplanned excision of soft tissue sarcomas (STSs) outside comprehensive tumor management centers necessitates the need for wide reexcision to achieve adequate margins. We retrospectively reviewed medical records of 135 patients with STS operated at our hospital with the goal of examining outcomes, in terms of local recurrence (LR) and metastasis rate (MR), of reexcision following unplanned excision of STS and comparing results with those of first-time planned surgery. Eighty-four patients had their first-time surgery and 51 patients had come to us following unplanned excision at prereferral hospital. Mean age of all patients was 41.8 ± 21.9 years. The LR and MR was 14.3% and 8.3%, respectively, in patients undergoing first resection, whereas it was 21.4% and 13.7%, respectively, in patients undergoing revision surgery. Average duration from previous unplanned excision was 8 months. Twelve patients were referred immediately after excised specimen revealed STS, while 39 patients presented after evident local recurrence. Wide reexcision was attempted in 48 patients while three patients need amputation. Adjuvant radiotherapy was administered in all patients undergoing limb-sparing surgery. Ten patients needed adjuvant chemotherapy. We conclude that wide reexcision of STS has poorer outcomes compared to planned excision. Therefore, patients with soft tissue masses should be managed by multidisciplinary oncology team at specialized cancer centers.

EuroSCORE vs. EuroSCORE II vs. Society of Thoracic Surgeons risk algorithm.

Introduction This study presents a validation series for EuroSCORE II compared with the previous additive and logistic EuroSCORE and the Society of Thoracic Surgeons risk prediction algorithm. Patients and methods Clinical data of 2004 patients undergoing isolated coronary artery bypass surgery between 2006 and 2010 were retrospectively collected and individual expected risks of death were calculated by all 3 risk prediction algorithms. Performance of these risk algorithms was evaluated in terms of discrimination and calibration. Results There were 76 deaths (3.8%) among 2004 patients. The mean EuroSCORE II predicted mortality was 3.72% ± 5.11%, additive EuroSCORE was 4.35% ± 3.65% and logistic EuroSCORE was 6.41% ± 10.06%. The additive EuroSCORE was better than EuroSCORE II in terms of both discrimination and calibration (C-statistic 0.866 and Hosmer-Lemeshow p value 0.230 vs. C-statistic 0.836 and Hosmer-Lemeshow p value 0.013 for EuroSCORE II). In a subset of 380 patients, we compared EuroSCORE II with the Society of Thoracic Surgeons risk prediction. Actual mortality was 2.89%. Predicted mortality by EuroSCORE II was 4.27% ± 5.22% and Society of Thoracic Surgeons risk prediction was 2.30% ± 4.16%. The area under the curve was 0.759 for EuroSCORE II and 0.898 for the Society of Thoracic Surgeons risk prediction, whereas the Hosmer-Lemeshow p value was 0.267 for EuroSCORE II and 0.981 for Society of Thoracic Surgeons risk prediction. Conclusion The Society of Thoracic Surgeons risk prediction algorithm is a better risk assessment tool compared to additive and logistic EuroSCORE and EuroSCORE II in Pakistani patients.

Risk stratification analysis of operative mortality in isolated coronary artery bypass graft patients in Pakistan: comparison between additive and logistic EuroSCORE models.

We compared the performances of the additive and logistic EuroSCORE in predicting mortality in patients undergoing isolated coronary artery bypass grafting at a single institution in Pakistan. Both models were applied to 2004 patients, operated upon at the Aga Khan University Hospital from January 2006 to July 2010. The actual mortality (3.8%) was significantly different from the additive (4.35%) and the logistic (6.41%) estimates. On the basis of degree of risk, actual mortality was 0.6% in the low-risk (additive EuroSCORE 0-4), 4.2% in the medium-risk (EuroSCORE 5-9) and 19.1% in the high-risk (EuroSCORE 10-19) group. With the low risks, both systems slightly overestimated mortality, with the logistic EuroSCORE being more accurate. At a EuroSCORE of between 10 and 19, the additive EuroSCORE underestimated and logistic EuroSCORE overestimated mortality. Both models satisfactorily discriminated outcomes (receiver operating characteristics areas of 0.866 and 0.859 for the additive and the logistic model, respectively). The Hosmer-Lemeshow test showed that calibration was good for the additive model (P=0.424) but turned out to be inadequate for the logistic model (P<0.001). We conclude that the additive EuroSCORE is a more accurate model for risk assessment compared to the logistics model in the Pakistani population.

Salvage of infected non-union of the tibia with an Ilizarov ring fixator

Purpose. To review outcomes of 24 patients who underwent Ilizarov ring fixation for infected non-union of the tibia. Methods. Medical records of 21 men and 3 women aged 13 to 74 (mean, 38) years who underwent Ilizarov ring fixation for infected non-union of the tibia were reviewed. The mean bone defect was 3.3 (range, 2–5) cm. The mean time from injury to presentation was 11.9 (range, 1–36) months. The mean number of previous surgeries was 2 (range, 0–14). A local flap was used in 2 patients and a free flap was used in one patient. Nine of the patients underwent Ilizarov ring fixation without soft tissue and bony resection, as inadequate stability was the reason for non-union. Patients were assessed using the Association for the Study and Application of the Method of Ilizarov criteria. Results. Patients were followed up for a mean of 11 (range, 8–46) months. Functional outcome was excellent in 8 patients, good in 12, fair in 2, and failure in one, whereas bone union outcome was excellent in 6 patients, good in 14, fair in one, and poor in 2. The mean time to union was 8 (range, 3–31) months. The mean external fixation index was 4.2 (range, 1.5–15.7) cm/month. Complications encountered were pin tract infection (n=5), re-fracture (n=2), soft tissue impingement by Ilizarov rings (n=2), recurrence of wound infection (n=1), mal-union (n=1), and mortality (n=1). Conclusion. Ilizarov ring fixation is a viable option for infected non-union of the tibia. Adequate assessment of bone union is crucial before removal of fixator to prevent re-fracture.

Managing soft tissue sarcomas in a developing country: are prognostic factors similar to those of developed world?

BackgroundManaging soft tissue sarcomas (STS) in a developing country with limited financial resources and a poor health referral system is a challenge. Presenting late, these extremity STS are prone to recurrence despite apparently complete resection. This study aimed to explore and compare the impact of clinico-pathological factors on recurrence and survival in Pakistan with the corresponding figures quoted from the developed world.MethodsAn institutional review was performed on all patients with primary STS of the extremities operated on between 1994 and 2008. The prognostic influence of clinical, pathologic, and treatment variables on local recurrence free survival (LRFS), metastasis free survival (MFS) and overall survival (OS) were analyzed by univariate and multivariate Cox regression analysis and Kaplan Meier survival curves.ResultsA total of 84 patients with a mean age of 41.8 ± 21.9 years were included in the study. The local recurrence rate was 14.3% after a median of 6 (mean 7.4) months. Metastases occurred in 7 patients (8.3%) and 65 patients were alive without evidence of disease after a mean follow-up of 52.6 ± 39.8 months. Tumor size > 5 cm, grade 3 tumors and margin < 10 mm significantly increased local recurrence rates. A margin ≥ 10 mm and age < 45 years significantly enhanced cumulative survival. Significant multivariate risk factors for metastases were margin < 10 mm and tumor grade G3.ConclusionsDespite a poor health referral system in our country, our results are no different from those reported from the developed world. Surgical margins and tumor grade prognostically influenced LRFS, MFS and OS.

Use of femoral nail with spiral blade in subtrochanteric fractures

OBJECTIVE The aim of this study was to evaluate the outcome of acute subtrochanteric fractures managed with intramedullary nail and spiral blade fixation of the proximal fragment. METHODS Charts of 33 patients (17 males and 16 females) with acute subtrochanteric fractures operated with intramedullary nail and spiral blade at our institution between March 2006 and February 2011 were retrospectively reviewed. The most common (67%) mechanism of injury was ground-level fall, predominantly involving elderly patients. Results were evaluated in terms of union time, implant failure rate, infection rate and functional outcome. RESULTS Mean duration of surgery was 2.4 hours and average length of hospital stay was 7 days. Mean radiological healing time was 16 weeks. Good healing occurred in 31 (94%) patients within 6 months of surgery. Uneventful healing occurred in 28 (85%) patients and 3 (9%) had delayed healing requiring dynamization in two patients and bone grafting in one. Implant failure occurred in 2 (6%) patients within 2 months of index surgery requiring repeat surgery. One (3%) patient had varus malunion. CONCLUSION Intramedullary nailing with spiral blade is a good option for acute subtrochanteric fractures with promising results. We think that this is a superior device compared to conventional methods of fixation for subtrochanteric fractures.

Isolated adult hypoganglionosis presenting as sigmoid volvulus: a case report

IntroductionIsolated hypoganglionosis is a rare cause of intestinal innervation defects. It is characterized by sparse and small myenteric ganglia, absent or low acetylcholinesterase activity in the lamina propria and hypertrophy of the muscularis mucosae, principally in the region of the colon and rectum. It accounts for 5% of all intestinal neuronal malformations. To the best of our knowledge, only 92 cases of isolated hypoganglionosis were reported from 1978 to 2009. Isolated hypoganglionosis usually manifests as enterocolitis or poor bowel function, and is diagnosed in infancy or childhood. We report the first case of isolated hypoganglionosis presenting with sigmoid volvulus in a 34-year-old woman.Case presentationA 34-year-old Asian woman had progressively increasing abdominal pain and had not passed stool or flatus for two days. A physical examination revealed a distended abdomen with sluggish gut sounds. A computerized tomography (CT) scan demonstrated gross dilatation of the sigmoid colon (maximal diameter 14.3 cm) suggestive of sigmoid volvulus. During emergency laparotomy, sigmoidectomy with a side-to-side colorectal anastomosis was performed. Histopathology of the resected specimen showed occasional ganglion cells and hypertrophied nerve bundles in the muscle layers, suggesting hypoganglionosis. Colonoscopy was performed, and multiple full-thickness biopsies were taken that showed hypoganglionosis of the entire large bowel. Our patient underwent total colectomy with an ileorectal anastomosis. Subsequently our patient reported a dramatic improvement in her bowel function.ConclusionsIsolated hypoganglionosis is a rare cause of intestinal dysganglionosis and cannot be differentiated from Hirschsprungs disease based on clinical presentation. This case report describes an atypical presentation of the disease. A definitive diagnosis requires histopathological analysis of full-thickness intestinal biopsies. Treatment should be tailored to the extent of hypoganglionosis.