Objectives:To assess the advantage of selective use of shunt in carotid endarterectomy (CEA) under local anesthesia. Materials and Methods: A total of 122 consecutive patients fulfilling international guidelines were included. Shunt was used selectively only in cases of bilateral severe carotid artery occlusive disease or in those patients who developed neurological symptoms on clamping of carotid artery. Follow up was done weekly for one month; then every month for 3 months; and then every 3 months for a year. Results: Shunt was used only in 5% (n = 6) patients. Of these, 2.5% (n = 3) patients were those who developed neurological symptoms on clamping the internal carotid and deployment of shunt resulted in complete resolution of symptoms. 2.5% (n = 3) had severe bilateral carotid stenosis and shunt was deployed. One of these patients developed stroke which was permanent. There was no mortality. The mean procedure time was 170 min in patients in whom shunt was used, when compared with 100 min in patients without shunt (P = 0.003). Conclusion: Use of shunt in carotid endarterectomy under local anesthesia as selective policy has an advantage in terms of cost effectiveness, operation time and prevention of potential complications.Keywords: shunt, carotid artery, surgery, local anesthesia, advantage in asymptomatic disease and higher in symptomatic patients. 1) The major risk factors are advanced age, male gender, smoking and diabetes mellitis. 2,3) To make stroke free survival carotid endarterectomy (CEA) is performed in asymptomatic and symptomatic patients with ≥70% and ≥50% stenosis of internal carotid artery respectively. 4,5) Perioperative strokes mostly are due to ipsilateral diseased carotid but some may be due to carotid artery clamping resulting in brain ischemia. 4) The duration of interrupted blood flow can be reduced by using a shunt to fulfill circulatory needs of the brain. CEA can be performed under local or general anesthesia with routine or selective use of shunt. 4,5) Potential disadvantage of using shunt during CEA include increase in operation time, dislodgement, bleeding, dissection of artery, tear in the artery wall, air or plaque embolism and increased local complications like nerve injury, infection, hematoma and long term stenosis. 6) However, reliable data is limited. 7) Selective use of shunt in cases of bilateral severe carotid artery occlusive disease and in those cases which developed neurological symptoms on clamping of carotid artery, can reduce shunt induced complications. 7) Keeping in view these international reviews and scarcity of guidelines in our national literature, we performed this study in our department with selective use of shunt to assess shunt related perioperative morbidity. Materials and MethodsAll consecutive patients reporting to the department of Vascular Surgery in Combined Military Hospital Lahore between January 2012 to January 2015; with documented narrowing of carotid artery occlusive disease, were included in this study. Of these, patients who were symptoma...
Background: Acute Appendicitis (AA) is the commonest surgical emergency encountered by surgeon in public & private setup in Pakistan. When it comes to diagnosis, patient seldom presents with the typical bookish picture (symptoms / signs) of the condition. Diagnosis therefore remains an enigma many a times especially for house officers and residents during their emergency duty. Various scores had been developed to aid the diagnosis, Alvarado score although gained popularity and is practiced in our setup. This study was designed to evaluate one such score designed by JM Ramirez & J Deus, for its negative appendicectomy rate calculation with the view to adopt it to our routine practice if it turns out with lesser negative appendicectomy rate compared to other scores in practice. Methods: This descriptive study was designed & carried out at the Surgical “B” Unit of Ayub Teaching Hospital Abbottabad from November 01, 2020 to June 30, 2021. A total of 190 patients with suspected AA were included, assessed by the score and accordingly placed in three groups based upon their initial score. Group-I patients were discharged with the advice to come back to same unit / hospital if pain persists or recurs. Group-II patients were kept in observation for 24 hours and finally re-categorized either as Group-I or Group-III based upon a drop or rise in their score. Group-III patients were operated after preparation. Data collected over a special proforma was finalized at the time of discharge of patient, earlier in case of group I patients or after getting histopathology report in case of Group-III patients that was later analyzed with the help of SPSS-version 26. Results: Out of 190 patients included in study 129 were male while 61 were female patients. 49 patients presented with a score less than –15 (Group–I) & were discharged after evaluation. 53 patients had a score between –15 to 09 (Group–II), were therefore kept under observation till next 24-48 hour. Score of 30 dropped to Group-I range & were similarly discharged like Group-I patients. Score of 23 patients rose up to 10 or above (i.e. Group-III range) & were therefore operated like other 88 patients belonging to Group-III. 91 patients were having acutely inflammed, phlegmonous, gangrenous, perforated appendix or appendix with impacted faecolith / pus in the lumen, their appendicectomy specimen along with the specimen of 20 other difficult to diagnose cases on gross vision were sent for histopathology. H/P report confirmed 100 as positive & 11 as negative for appendicitis. 111 patients totally got operated, out of which 11 turned out negative appendicectomies. Frequency of negative appendicectomies overall was therefore 09.9%. It was 05.56% in male (i.e. 04/72) and 17.94 % (i.e. 07/39) in female patients. Conclusion: Score developed by JM Ramirez and J Deus proved quite helpful in the diagnosis of acute appendicitis & reduction of the frequency of Negative appendicectomies. Being simple, non-invasive & cost-effective, requiring no special equipment or investigations for its application, it ensures an instant, structured & thorough assessment of patient. The score is therefore recommended for its routine adoption / application in our setup in the diagnosis of acute appendicitis to reduce the frequency of negative appendicectomies. Keywords: Acute appendicitis, frequency of negative appendicectomy, scoring system, Ayub Teaching Hospital
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