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Objective: To compare the frequency of anastomotic leakage in interrupted versus continuous, single layer extramucosal anastomotic techniques in jejunum. Study Design: Quasi-experimental study. Place and Duration of Study: Combined Military Hospital, Multan Pakistan, from Feb 2020 to Feb 2021. Methodology: Patients aged 15-60 years, from the indoor surgical department of the hospital who required jejunal anastomosis were selected. Patients were categorized as Group-A (interrupted single layer extra mucosal anastomosis) or Group-B (continuous single layer extra mucosal anastomosis). Results: The mean age was 43±9.5 years in Group-A and 41.6±10.1 years in Group-B. Eighteen patients (56.3%) in Group-A and 21(65.6%) in Group-B were male while 14 patients (43.67%) in Group-A and 11(34.4%) in Group-B were females. Frequency of anastomotic leakage was recorded as one patient (3.13%) in Group-A and 3(9.38%) in Group-B while rest of the patients in both groups had no anastomotic leakage (p=0.302). Chi square test was applied, which showed statisticaly insignificant difference between the two groups (p=0.32) Conclusion: Comparatively higher frequency of anastomotic leakage was recorded in patients treated with continuous as compared to interrupted suturing but the results were statisticaly insignificant. [ABSTRACT FROM AUTHOR]

Objective: To determine the efficacy of fixing chest tube to chest wall from both sides versus single side fixation with silk one suture. Study Design: Comparative cross sectional study. Place and Duration of Study: Combined Military Hospital, Kharian Pakistan, from Mar 2021 to Jan 2022. Methodology: Two hundered Patients undergoing chest intubation at CMH Kharian and referred from peripheral hospitals were considered in the study and divided into two groups. In our setup (Group-A), chest tubes were fixed with a chest wall with silk breaded sutures from both sides, compared to patients referred from peripheral hospitals (Group-B), who had chest tubes fixed to the chest on a single side. They were analyzed for system leakage at the chest wall, to and fro movements of the chest tube and accidental dislodgement. Results: Unilateral chest intubation was done in 193(96.5%). Right sided intubations were 112(56%) and 81(40.5%) were left sided. Most chest intubations done were either blunt or penetrating thoracic trauma 52(26%), early empyema thoracis 50(25%), primary pneumothorax 30(15%), indeterminate pleural effusion 28(14%), secondary pneumothorax 24(12%) and malignant pleural effusion 16(08%). System leakage was 2(02%) in group A to 13(13%).No chest tube was moved to and fro in Group-A and 12(12%) in Group-B. In Group-A, accidental dislodgement was 3(03%), and 6(06%) patients had such complication in Group-B. Conclusion: Chest tube fixation with chest wall with silk one breaded suture gives better support to the chest tube from all sides and minimizes the chances of system leakage, to-and-fro movements, and accidental dislodgement compared to fixation of the chest tube from only one side. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the safety profile of Hasson’s technique of laparoscopic port access in patients undergoing laparoscopic cholecystectomy. Study Design: Cross-sectional study. Place and Duration of Study: Department of general surgery, Combined Military Hospital Lahore, from Oct 2014 to Aug 2018. Methodology: A total of 1037 patients with acute or chronic cholecystitis who were scheduled for laparoscopic cholecystectomy were included. Hasson (open) technique was used to insert first laparoscopy port for creation of pneumoperitoneum. Following laparoscopic cholecystectomy, data of intra-operative and post-operative complications was noted. Patients were followed during hospital stay to evaluate any procedure related injury. Follow-up was done at up-to six months to determine wound infections and formation of umbilical hernia. Results: Mean age of the patients was 44.65 ± 8.98 years. Out of 1037 patients, procedure was simple in 655 (63.16%) patients and complex in 382 (36.83%) patients due to the presence of inflammatory adhesions and anatomic access. There was no intra-abdominal injury, omental injury, vascular injury or gut perforation. Port-site infections were diagnosed in 6 (0.57%) patients during 06 months’ follow-up. Umbilical hernia was diagnosed in only 1 (0.09%) patient. Conclusion: We found that Hasson technique of first laparoscopy port access for creation of pneumoperitoneum was a safe technique with minimum number access related complications. [ABSTRACT FROM AUTHOR]

Objective: To find out the occurrence of Asymptomatic COVID-19 in emergency surgeries performed from 23 Mar to 23 Jun 2020 in three tertiary care hospitals and analyze the distribution of cases. Study Design: Cross sectional study. Place and Study Duration: Departments of Surgery, Combined Military Hospital Multan, Lahore and PNS Shifa Karachi, from Mar 2020 to Jun 2020. Methodology: All cases requiring emergency surgical procedures were first assessed for clinical symptoms of COVID-19 and urgency for surgical intervention. Test for COVID-19 were advised in addition to baseline as per hospital policy. Patients requiring urgent intervention were operated using personal protective equipment (PPE) without waiting for COVID-19 test result while other emergency patients were operated after COVID-19 results within 24 hours. Results: Total 1941 patients were operated 678 (34.9%) in CMH Multan, 723 (37.2%) in CMH Lahore and 540 (27.8%) in PNS Shifa. Out of total 95(4.89%) patients were positive 57 (60%) male positive patients and female 38 (40%). Age distribution was max above 50 years with 33 (66%), only 13 were less than 20 years of age. All patients were clinically symptom free as per COVID-19 criteria of NIH Conclusion: Of 4.89% patient can be missed COVID-19 cases if screening is not carried out in all patients undergoing surgery. Picking of these asymptomatic cases is rather more important as they can trigger spread in the healthcare workers and adversely affect the already overburdened health care delivery system in a close contact environment. [ABSTRACT FROM AUTHOR]

Objective: To analyze results of triage sorting, weekly turnout of positive cases and their mortality and to see the pattern of emergency surgeries in various disciplines. Study Design: Cross sectional study. Place and Study Duration: Department of Surgery, Combined Military Hospital, Multan, from Mar 2020 to Jun 2020. Methodology: National Institute of Health Pakistan guidelines 2020 on COVID-19, for admissions and contact tracing were adopted. Group A patients were admitted with strong clinical suspicion of COVID-19 based on high risk score. Group B patients presented for contact tracing and Group C were surgical emergencies. Lab, Triage counter and isolation ward records were analyzed. Results: Out of 408 admitted patients, 293 were males while 115 were females. 167 (40.9%) were positive. 74/167 had comorbid 5 of these died. The case fatality rate was 3% (p-value 0.01). In contact tracing, the secondary attack rate was 2.56%. Maximum positive trend was observed in the last 4 weeks which is consistent with the exponential rise in local and national cases. 424 surgeries were performed and 12 /424 were positive for COVID- 19. Conclusion: Screening of symptomatic patients showed Positive Predictive Value of 41% and sensitivity of 67.6%. Significant number of patients will be missed because of low sensitivity of this method. So, we recommend using Polymerase Chain Reaction as a screening modality. Symptomatic patients are likely to be positive in an area where the incidence of disease is greater. [ABSTRACT FROM AUTHOR]

Objective: To determine the effectiveness of the haemorrhoidal artery ligation via palpatory method among patients with grade II and III hemorrhoids. Study Design: Observational prospective study. Place and Duration of Study: The study was conducted at Combined Military Hospital Multan where with hemorrhoids were operated between May to Nov2018. Methodology: A total of 121 patients participated in this study. Patients included in the study were aged between 20-60 years of age with grade II and III hemorrhoids. Patients were selected from out-patient department. They were explained the purpose of the study and those who consented to participate in the study were enrolled through a written consent form. Digital rectal examination was done under spinal anesthesia followed by proctoscopy and hemorrhoids were identified. Split proctoscope was passed and hemorrhoids were isolated one by one. Haemorrhoidal artery was palpated sutured with vicral 3/0. Follow up at 3weeks and 8 weeks. Results: Male respondents accounted for 50 (41.3%) whereas their female counterparts comprised 71 (58.7%). The mean age of the male and female respondents was 43.76 ± 10.08 and 44.52 ± 10.59 years respectively. Out of 121 patients that underwent haemorrhoidal artery ligation, only 33 (27.3%) had post-operative complications. Most of the patients had rectal bleeding followed by post-operative defecation pain, anal fissure, fistula in ano and recurrence Conclusion: In conclusion, palpatory method is painless, less invasive, has less complications and is safe alternative to open hemorrhoidectomy where Doppler guided haemorrhoidal ligation equipment is not available. [ABSTRACT FROM AUTHOR]

Objective: To check the awareness of surgical procedures in the soldiers and their families Study Design: Cross-sectional questionnaire-based study. Place and Duration of Study: Combined Military Hospital Lahore Pakistan, from Aug 2016 to Mar 2017. Methodology: Patients were selected purposely from different wards. A questionnaire was devised and it was circulated among the house officers who got them filled during their ward rounds by interviewing the patients. Inclusive criteria included the Patient who were pre-operative, who were on elective operation list. Results: Mean age of the patient was 50.5 ± 10 years. Patients ranged from 18 to 84 years. Majority of the patients were uneducated. Mean duration of the stay of the patient at the hospital was 8.5 ± 2 days. 28.5% of the patients did not about the disease. 36.5% of the patients did not know the name of the surgeon who was operating. 46.5% of the patients did not know the specialty of the surgeon. 46.5% of the patients did know the surgical intervention required. 49% of the patients were not told about the surgical intervention required. 84% of the patients did not know the complications of the surgery. Despite all, 97.5% of the patients were satisfied with the care given to them. Conclusion: The patients were not adequately aware of the information that they need to have for the operation they were being operated. It is the right of the patient to know benefits and risks of the treatment he or she is going to get. Similarly, it is the duty of the doctor to deliver the adequate information, which is clear and understandable to him/her as it the matter of the life of the patient. [ABSTRACT FROM AUTHOR]

Objective: To identify the gaps in knowledge of medical ethics among undergraduates. Study Design: An observational cross-sectional study. Place and Duration of Study: The study was conducted at CMH Lahore medical College, from Aug 2017 to Mar 2018. Methodology: Students from 3rd to 5th year MBBS were included in this study. Sample size calculated was 272, non-probability consecutive sampling technique was used. To collect the data, a 25 item questionnaire was developed following An International Association for Medical Education (AMEE) guide line number 87. Five point likert scale was used as well as categorical yes/no questions were asked to assess the responses. Results: Data were collected from 3rd year to 5th year MBBS undergraduates. Response rate was 82.72%. There was almost equal gender distribution; 51.1 % were male and 48.9% were female. Most of the respondents, 95.6% and 95.1% were of the view that medical ethics are important and should be taught at undergraduate level respectively. Majority 72.4% said Hippocrates declaration oath was not taught adequately. Only 42% and 46% were aware of medical ethics regarding publication and organ transplant respectively. Total score was calculated which showed that knowledge of medical ethics was highest among 3rd year and lowest among 4th year medical students. Conclusion: Important ethical issues are being neglected in our current curriculum. [ABSTRACT FROM AUTHOR]

Objective: To determine the demographic variance in location and histopathological findings of esophageal carcinoma in Punjab-Pakistan. Study Design: Observational cross sectional study. Place and Duration of Study: This study was conducted in Multicentre Tertiary Care Hospitals of Combined Military Hospital/Pak Emirates Military Hospital/Army Medical College Rawalpindi, Combined Military Hospital Kharian and Combined Military Hospital Multan from 2010 to 2017. Methodology: Patients with dysphagia and histopathology proven malignancy were included in this study. All patients had undergone flexible upper gastrointestinal endoscopy. Patients with lesions other than carcinoma, causing dysphagia and those with inconclusive histopathology were excluded from our study. The morphological site of the carcinoma were divided into upper, middle, lower and at gastro-esophageal junction. Histo pathologically proven carcinoma of esophagus was reviewed for subtype of grading differentiation. Statistical analysis was done using IBM version SPSS 22. Results: Out of 150 patients, 85 (57%) were males and 65 (43%) were females. Their age ranged between 30 to 85 ± 12.33. Among one hundred and fifty patients 107 (71.33%) had Squamous Cell Carcinoma, 42 (28%), Adenocarcinoma and metastasis in two cases. Frequency of distribution of esophageal carcinoma in North, East and South Districts of Punjab was 73%, 18% and 9% respectively. Esophageal Carcinoma in upper, middle, lower and Gastroesophageal junction was 22.5%, 35%, 15% and 27.5% respectively. Frequency of well differentiated SCC was 46 (30.6%) and well differentiated AC 31 (20.7%) respectively. Conclusion: SCC with male preponderance is more common in North of Punjab. Lower 1/3rd and GE junction esophageal tumor are the commonest sites in all North, East and South Punjab. Histopathological differentiation revealed Well Differentiated SCC along with significant rise in Adeno-carcinomas compared to previous national studies. [ABSTRACT FROM AUTHOR]

Objective: To share experience about enteral nutrition via feeding jejunostomy in patients undergoing esophagectomies or for palliative purposes and compare our findings with similar studies. The objective of this study is to show the safety/viability of the procedure in patients undergoing esophagectomies and as a palliative procedure in inoperable CA esophagus. Study Design: Observational study. Place and Duration of Study: CMH Lahore and CMH Rawalpindi, from 2010 to 2016. Material and Methods: Feeding jejunostomy is a surgical technique for placement of a feeding tube into small intestine mainly for administration of nutrition. Our method was based upon Witzel jejunostomy technique with emphasis on early postoperative commencement of enteral nutrition & achievement of target caloric and protein requirement subsequently. A total of 439 patients who underwent feeding jejunostomy were included. These include patients suffering from any benign or malignant pathology for which esophagectomy was done and those patients who are suffering from inoperable carcinoma and underwent feeding jejunostomy for palliative purposes. Results: Result and price analysis shows that feeding jejunostomy is financially viable as per day nutrition cost for feeding via total parenteral nutrition (TPN) is Rs 8500 ± 500 (including required daily labs) and for enteral its around 560 ± 40 Rs/day. None of our patient was put on TPN and none suffered from malnutrition. Percentage of complications rendered were on par with the results from similar studies and meta-analysis. Conclusion: We conclude that feeding jejunostomy is financially viable with minimal complications, that justifies its use and its superiority over TPN. [ABSTRACT FROM AUTHOR]

Medical ethics is a core issue for all specialties and is encompassed in professionalism. It is a presumption that not dealt appropriately in the undergraduate teaching curriculum. There is a paucity of awareness lectures and seminar workshops in teaching setups for medical ethics for undergraduates in developing countries. The current policy of PMDC does not provide a centralized curriculum for teaching of medical ethics in medical colleges, which results in lack of logical ethical reasoning among students. There is a need to develop a medical ethics curriculum taught by medical ethics department in every medical college in collaboration with the clinicians with real life case scenarios. Students should be evaluated through examinations at the end of every year with fixed hours dedicated to the teaching of the curriculum. Only, through these measures patient satisfaction will improve and medicine can achieve its lost glory and nobility in our part of the world. [ABSTRACT FROM AUTHOR]

Objective: To evaluate clinical judgment in ruling out pneumothorax during the removal of the chest tube by auscultating the chest before removal and after the extubation of the chest tube in comparison to x ray radiological results. Study Design: Descriptive cross sectional study. Place and Duration of Study: Combined Military Hospital (CMH) Lahore Pakistan, from August 2015 to March 2016. Material and Methods: A sample size of 100 was calculated. Patients were selected via non probability purposive sampling. Children under 14 years were not included. The patients with mal-positioned chest tube, surgical site infection, air leak and the patients with more than one chest tube on one side were excluded. A proforma was made and filled by one person. Chest tubes were removed by two trained senior registrars according to a protocol devised. It was ensured that there was no air leak present before removal clinically and radiologically. Another chest x-ray was done within 24 hours of extubation to detect any pathology that might have occurred during the process. Any complication in the patient clinically was observed till the x-ray film became available. Two sets of readings were obtained. Set A included auscultation findings and set B included x ray results. Results: Out of 100 patients, 60 (60%) were males and 40 (40%) females. The ages of the patients ranged between 17-77 years. Mean age of the patient was 43.27 ± 17.05 years. In set A out of 100 (100%) no pneumothorax developed clinically. In set B out of 100 patients 99 (99%) showed no pneumothorax on chest x ray, only 1 (1%) showed pneumothorax which was not significant (less than 15% on X ray). However, the patient remained asymptomatic clinically and there was no need of reinsertion of the chest tube. Conclusion: Auscultatory findings in diagnosing a significant pneumothorax are justified. Hence, if the chest tube is removed according to the protocol, clinically by auscultation we can be sure that no significant pneumothorax developed during extubation, thus there is no need of x-ray after wards. [ABSTRACT FROM AUTHOR]

Objective: The study was carried out to ascertain the outcome of laparoscopic modified Heller's myotomy for achalasia cardia and to determine the morbidity associated with it. Study Design: Descriptive cross sectional study. Place and Duration of Study: The study was conducted in Combined Military Hospital (CMH) Rawalpindi over a period of 4 years, from Jan 2010 to Aug 2014. Material and Methods: This study was carried out on patients undergoing surgical repair of laparoscopic Heller myotomy for cardiac achalasia at Combined Military Hospital Rawalpindi over a period of four years (2010-2014). Patients undergoing laparoscopic-modified Heller myotomy at a thoracic referral and surgical training center. Eighteen cases of achalasia cardia based on clinical, barium and endoscopic findings were included in the sample using non probability purposive sampling technique. Pseudo achalasia, sigmoid esophagus were excluded. Laparoscopic modified Heller myotomy was done in all patients. Data were analyzed with the help of SPSS 20.0. Results: Age ranged between 14 years to 40 years with mean age of 28 years. The most frequent symptom was dysphagia (95%), followed by regurgitation of ingested food (60%), weight loss (40%) and chest pain (20%). Mean operating time was forty minutes. There was no perioperative mortality. We applied Dor patch in 4 patients. Three patients had mucosal tear on large myotomy, diagnosed per operatively and repaired. There was no conversion to open procedure. There was marked improvement in symptoms especially dysphagia and there was no post operative reflux. Conclusion: Modified Heller myotomy by laparoscopic approach is a safe and effective procedure with acceptable results. It is easy to perform and improves the symptoms of the suffering individual. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to evaluate outcome of chest tube removal without clamping and relying only on clinical or radiological status for removal. Study Design: Retrospective descriptive study. Place and Duration of Study: The study was conducted in CMH Rawalpindi over a period of four years. Material and Methods: All patients of tube thoracostomies during Jan 2010 to Dec 2013 were included. Sample size was 2661. 1061 intubations were done for trauma, effusions and pneumothoraces, 905 in thoracostomies, 443 in VATS procedures like decortications, apical staplings, pleural biopsies and thymectomies and 252 in miscellaneous procedures such as open pleural biopsies, thoracoplasties and chest wall resections and reconstructions. Chest tube removal was based on absence of air bubbling in chest bottle, clinically or radiologically expanded lung, less than 6 cm excursion of column of chest tube and fluid output of <50ml (pus) and <100ml (clear fluid). It was ensured in all cases that chest tube was not blocked and all tubes were removed by a thoracic surgery trainee. Chest tube was not clamped in any patient before removal to see respiratory distress. Results: Tube thoracostomies were performed in a vast variety of procedures. 1940 (72.9%) were males and 721 (27.1%) were females. Mean age was 37 years. In 1529 (57.4%) intubation was done on the right side. In 34 (1.27%) there was recurrent fluid collection. Recurrent pneumothorax was seen in 18 (0.67%) while tension pneumothorax was seen in 4 (0.15%). Collective complication rate was in 56 (2.1%). There was no mortality. Conclusion: Current worldwide practice of clamping chest tube before removal to judge respiratory distress can be challenged by our study. Emphasis is laid on clinical judgment, absence of air leak and minimal excursion sign of well expanded lung before removal of chest tube. [ABSTRACT FROM AUTHOR]

Objective: To identify the frequency of anomalies associated with chest deformity in physical fit male candidates reporting for military recruitment. Study Design: Observational. Place and Duration of Study: Department of Thoracic Surgery, CMH Rawalpindi from 1st Jan 2008 to 31 Dec 2011. Patients and Methods: Normal healthy physically fit young adolescents being recruited for army were scrolled and those exhibiting chest deformity were isolated and subjected to evaluation. Convenience sampling was carried out. All candidates of chest wall deformity thereafter underwent a thorough physical checkup, pulmonary function tests and echocardiography. Results: A total of 3735 candidates of chest deformity reported at our center for evaluation over this duration. Single deformity patients 3380 (90.5%), mixed deformity patients 355 (9.5%). We found that none of the candidates had any derangement of the lung function tests or electrocardiographic abnormality despite their deformity. However echocardiography detected an abnormality in 161 (4.3%) individuals who were otherwise asymptomatic. Conclusion: Chest deformity should be excluded before physical tests, in all the male candidates reporting for enrolment. If slightest of doubt exists that a candidate has chest deformity then he should be evaluated with echocardiography to exclude cardiac abnormality. Although the associated frequency is only 4.3% but this can subsequently result in a grave event like death. [ABSTRACT FROM AUTHOR]

A 49-year-old Pakistani male presented with "heaviness" in his chest. Chest radiograph and computed tomography (CT) confirmed a massive left-sided pleural-based opacity. Three years ago, he was investigated for a left-sided lymphocytic, exudative pleural effusion following an episode of dengue fever. Tube thoracostomy removed 1.3 L of fluid. Pleural biopsy and bronchial washings were non-contributory. He received empirical antituberculosis treatment and remained asymptomatic until this presentation. To investigate the new pleural mass, he underwent a video-assisted thoracoscopic surgery, which revealed a 2.2 kg mass in the pleural cavity involving the anterior mediastinum and chest wall and adhered to the visceral pleura. Following conversion to an open thoracotomy, the mass was completely excised, which involved non-anatomical lung resection. Histopathology and immunohistochemistry of the resected tumour were consistent for a desmoid tumour. He was followed up for 9 months with no evidence of tumour recurrence. Predominantly pleural-based desmoid tumour is rare but should be included in the differential diagnosis of spindle cell tumours. [ABSTRACT FROM AUTHOR]

A middle aged man presented with a solitary pulmonary nodule. He had a diagnostic dilemma as the CT guided FNAC was inconclusive. The frozen section exam reported it to be malignant so a lobectomy was performed for this lesion. The final histopathology report confirmed it to be a very rare tumor of extra skeletal synovial sarcoma. [ABSTRACT FROM AUTHOR]

Objective: To analyze the outcome of Video assisted Thoracoscopy (Vats) in Primary Spontaneous Pneumothorax (PSP)., Methods: This case series was carried out from Jan 2010 to Jan 2017 in Department of Thoracic Surgery CMH Rawalpindi and Lahore. A total of 98 patients underwent Video-assisted thoracoscopic for PSP. Inclusion criteria were physiologically fit patients with PSP for recurrent attacks, occupational hazards and prolonged air leak. Exclusion criteria included secondary spontaneous pneumothorax, previous pleurodesis and physiologically unfit patient for general anaesthesia. Vanderschueren's thoracoscopic classification was used for macroscopic staging. A 3-port technique was used for apical stapling with partial pleurectomy up to 6th rib. Parietal pleura and diaphragm was also abraded., Results: Occupational hazard was the commonest indication for surgery, n= 39 (39.7%). This was followed by recurrent pneumothorax 37 (37.7%), persistent air leak 19 (19.38%) and contra lateral pneumothorax n=4 (4.08%). Mean age was 22.8 ± 6.5 years. Majority of the cases , 69(70.4%) were in stage 3 of Vanderschueren's classification. Stage 4 were (18.5%) and stage 2 were 7 (7.14%). Mean operative time was 51 ± 14. 4 minutes. Postoperative prolonged air leak occurred in 3 patients and post-operative neuralgia occurred in 8 patients. Mean follow-up was 22 ±5.5 months, range 5-24 months for all patients. One had generalized recurrence and 2 patients had subpulmonic trapping of air., Conclusion: Video-assisted thoracoscopic stapling and pleurectomy is an effective definitive treatment for primary spontaneous pneumothorax when indicated with minimal recurrence.

Lung cancer is the most common cancer in males and second most common in females after breast cancer. We have compared our data with the international statistics to see where do we stand. In Pakistan, we do not have a valid central cancer registry at present which can provide a true picture of lung cancer. Therefore, we used statistics of GLOBOCON 2012, in order to evaluate the true burden of lung cancer in our population through the recently established data by PHRC (Pakistan Health and Research council). Our analysis showed that data depicting true incidence and mortality of lung cancer in Pakistan are lacking. GLOBOCON 2012 placed lung cancer as the 3rd most common cancer in Pakistan while PHRC 2016 placed it as the 10th most common cancer irrespective of the rise in smoking incidence in Pakistan over the past one decade. This calls for an urgent need to formulate a valid central cancer registry in the country in association with the local bodies.

Background: Foreign body bronchus is a surgical emergency and is associated with a high mortality if neglected or complicated. The objective of this study was to analyse the outcome of bronchotomy and resectional procedures after failed bronchoscopic foreign body retrieval., Methods: This study of 24 cases of bronchotomy and resectional procedures after failed bronchoscopic foreign body retrieval was done from June 2008 to June 2009 and March 2010 to Sep 2013. Patients after failed retrieval of foreign body by bronchoscopy either by ENT specialists or thoracic surgeons underwent bronchotomy or resectional procedures were included in the study. We used the posterolateral thoracotomy approach for the surgical procedures., Results: Bronchotomy and resectional procedures were done in 24 cases. Age of patients ranged from 2 years to 51 years. Most patients were children and right side was mostly involved. Bronchotomy procedures were 10 (41%) and resectional surgeries were 13 (58%). Emergency lobectonies were 3 out of 13 resectional surgeries. Right intermedius bronchus was opened up and incision was extended in the direction of foreign body in 6 cases and left bronchus intermedius was opened in 4 cases. Haemoptysis was the main symptom in late presenters. Range of objects retrieved in our study was from pins, needles to whistles., Conclusion: Retention causes endobronchial obstruction with stasis leading to irreversible damaged parenchyma. Foreign body with structural changes require resection, others can be offered bronchotomy which is a safe procedure for retained non retrievable foreign bodies.

Pulmonary arterio-venous malformation is an abnormal communication between pulmonary arteries and pulmonary veins. These lesions are rare and are an important part of the differential diagnosis of common pulmonary problems such as hypoxemia and pulmonary nodules. Pulmonary arterio-venous malformation was diagnosed in a 33 year old man who presented with recurrent episodes of haemoptysis and also had taken anti-tuberculous treatment (ATT) before. Pulmonary angiography revealed fistulous communication between right bronchial artery and right pulmonary vein. He was treated by lobectomy.