Iliocaval arteriovenous fistula presenting with multiple organ failure

Iliac arteriovenous fistulas are an uncommon condition, which may be spontaneous or traumatic in nature. Such fistulas classically present with a triad of high‐output cardiac failure, pulsatile abdominal mass with a bruit and unilateral leg ischaemia or venous congestion. We describe a case of an iliocaval fistula secondary to rupture of a common iliac artery aneurysm, with an unusual presentation of multiple organ failure, masquerading as sepsis. We describe the CT findings of iliocaval fistula, which was the means of diagnosis in this study.     

Sutureless closure of Operative Skin Wounds

Good tissue union and cosmetically acceptable scar is vital for ideal surgical practice. Since their discovery in 1949, cyanoacrylate compounds have evoked interest as being the ideal “tissue glue”. Several different forms of this compound have been developed in order to eliminate tissue toxicity. In this article, we have described a technique of sutureless closure of operative skin wounds and compared it to closure of skin with silk. Inter-group comparison was carried out with respect to the time required for closure, rate of infection, cosmesis and patient acceptance. N-butyl 2-cyanoacrylate was used for sutureless skin closure in 100 patients and compared with skin closure with sutures. The time taken to close the wounds with cyanoacrylate was found to be significantly less, the cosmetic outcome better and patient acceptability higher than when sutures were used.Key Words: N-butyl 2-cyanoacrylate, Skin closure     

Management of thromboangiitis obliterans using distraction osteogenesis: A retrospective study

Background:

Thromboangiitis obliterans (TAO), also known as Buerger disease, is characterized by thrombosis in medium-sized arteries and veins along with a marked inflammatory response. TAO can be managed by using the principle of distraction osteogenesis to induce neoangiogenesis. We report thirty patients of TAO in the age-group of 20–50 years were treated with the Ilizarov method.

Materials and Methods:

Patients with severe rest pain (n=30), absent distal pulsation (n=30) and ulcer (n=6) and/or gangrene of the toes (n=4), who had failed the conservative pharmacological modalities of treatment were included. A lateral tibial corticotomy was performed and distraction applied by use of olive wire. A two-ring frame was used for all cases.

Results:

Of the 30 cases, 25 patients became pain free while 1 had partial relief of pain. The four patients worsened on treatment and developed frank infection were amputed. The average distraction was 1.8±0.3 mm (range: 1.5–2.2 cm). The mean consolidation period was 98±11 days, after which the fixator was removed. The total duration of treatment was 122±23 days. There were two cases of osteomyelitis in our series; both healed after debridement and both patients had good result, with relief of pain. The ulcers started healing by 4–6 weeks.

Conclusion:

The principle of the distraction osteogenesis including neoangiogenesis can be used for treatment of TAO and has an acceptable complication rate.     

Does catheter choice during embryo transfer alter the pregnancy rate?

Background

Although every step in the in vitro fertilisation (IVF) procedure is important, the impact of embryo transfer (ET) on pregnancy rate (PR) is significant. Of all the crucial aspects of ET the type of catheter used and the technique of transfer on the PR has drawn the maximum attention and controversy. We aimed to compare the outcome of two different ET catheters on the PR.

Method

A prospective analysis comparing the classical Frydman (Laboratoire CCD, France) and the soft Cook (Cook Medical, Indiana, USA) ET catheters was performed. Primary end-point was clinical pregnancy rate (CPR); secondary end-points were rates of difficult transfer. A total of 1,446 ETs were performed in women undergoing IVF treatment, of which 723 cycles were randomised to the Cook catheter and 723 to the Frydman catheter.

Results

It was observed that, although the Cook catheter was related to a slightly higher PR, the overall comparison failed to indicate a significant difference in CPR. It was also seen that the ease of transfer did not significantly affect the PRs.

Conclusion

Individual variables during ET may not contribute significantly to the success of an IVF programme; however, a holistic approach encompassing all the factors is quintessential to improve the PR.     

Liver transplantation in Indian Armed Forces—initial experience

Background

This study retrospectively analyses the initial experience of liver transplantation (LT) in the Indian Armed Forces.

Methods

Fifty-three patients underwent LT at Army Hospital (R&R) Delhi Cantt. between March 2007 and March 2011. Of these 35 patients underwent deceased donor liver transplantation (DDLT) and living donor liver transplantation (LDLT) was carried out in 18 patients. The surgical techniques, complications and mortality were analysed.

Results

A high consent rate of 35.9% for organ donation was achieved by the Armed Forces Organ Retrieval and Transplantation Authority (AORTA). Biliary complications occurred in five patients (9.4%). However, most of them could be managed by endoscopic interventions. Hepatic artery thrombosis (HAT) occurred in five patients (9.4%). Of these, two DDLT grafts were revascularised following HAT, by creating extra-anatomic arterial conduits with excellent outcome. The overall mortality was 18.8% (n = 10). There was no significant difference in the overall complications or mortality in patients undergoing DDLT or LDLT.

Conclusion

The overall survival and morbidity in this study is comparable to those from other centres. Urgent revascularisation of grafts following HAT should be attempted as it can salvage grafts with satisfactory outcome. There is a reduction in the incidence of biliary complications with refinements in surgical techniques.