Traumatic false aneurysms in Port Moresby

BACKGROUND

Trauma is responsible for about 30% of surgical admissions in Port Moresby. Vascular injuries are frequently missed due to inadequate assessment by primary health care workers and often present late with large aneurysms which are difficult to manage. The aim of this study was to identify the patterns of morbidity associated with traumatic false aneurysms complicating vascular injuries in Port Moresby General Hospital from January 1995 to July 1999.

METHODS

A surgical database with 11,004 records was used to identify patients with a diagnosis of false aneurysm. Charts of patients with gunshot wounds, knife wounds and compound fractures were also reviewed to identify further cases with vascular injury.

RESULTS

51 patients were found to have had documented evidence of vascular injury requiring surgical repair within the study period. 21 patients with traumatic false aneurysm presented to Port Moresby General Hospital. 17 of the 21 patients were aged 11 to 40 years. There was only one female patient. Stab wounds (50%) were the commonest mode of injury followed by lacerations (23%) and fish bites (14%). The calf (42%), forearm (13%) and the head (13%) were the commonest sites involved. The time from insult to admission varied from 4 days to 11 years with the modal time being 14 days. Most patients presented with hard signs of false aneurysms (94%) and 81% of the patients were treated within five days. Ligation (67%) was the commonest operation, followed by excision (43%) and vascular repair (19%). There were no deaths or amputations in any of the patients with false aneurysms.

CONCLUSION

False aneurysms are a not infrequent complication of vascular injuries. Greater awareness of the possibility of vascular injury is needed. Patients in Port Moresby often present after considerable delay. However, the diagnosis can be made clinically and the results of surgical exploration are good. Although colour Doppler ultrasound is a useful investigation it sometimes fails to identify the aneurysm because it requires blood flow to be present in the aneurysm.

Neurosurgery in Papua New Guinea

BACKGROUND

An audit of neurosurgery in Papua New Guinea (PNG) based on the experience of a visiting neurosurgeon is presented. The objectives of the study were to determine the type and frequency of neurosurgical conditions in PNG, whether major neurosurgery can be performed successfully in PNG, and to develop a strategy for the development of neurosurgical services in PNG.

METHODS

The audit was carried out over two periods of 2 weeks duration in 1992 and 1993 in Port Moresby and Goroka. Instrumentation and equipment were limited and no additional equipment was used. Myelography and angiography were available in Port Moresby.

RESULTS

There were 82 patients in total, 55 (67.1%) were consultations, 23 (28%) had elective surgery, four (4.8%) had emergency surgery and 16 (19.5%) await surgery. Cases were subdivided into nine major groupings: neurotrauma 18 (seven severe); spine 18; congenital 13; hydrancephaly four; scalp, skull and orbit six; vascular three; peripheral nerve three; and neurology five. Seventy-two (87.8%) patients required CT/MRI which were unavailable. Four ventriculograms were performed in lieu of CT/MRI. Fifteen (18.3%) cases could not be treated in PNG.

CONCLUSIONS

Neurosurgical problems in PNG can often be adequately managed with limited resources. Complex procedures were performed with gratifying results and acceptable morbidity. There is sufficient pathology in a country of four million people to justify training a small number of neurosurgeons by the end of the decade. CT scanning will be a necessary adjunct.

Reconstruction of total loss of upper lip with hair-bearing flaps

Carcinoma of the lip is a relatively common problem in Papua New Guinea, accounting for some 12% of all malignant tumours in the oral cavity. The cancer is associated with chewing betelnut with slaked lime and smoking. Advanced squamous cell carcinoma of the upper lip is necessarily managed by primary surgery when radiotherapy facilities are not available. Adequate surgical treatment of these carcinomas usually requires full thickness excision of a portion or whole of the lip. The purpose of this paper is to demonstrate the role of hair-bearing scalp flap for reconstruction of total loss of the upper lip in male patients.

The repair of frontal encephaloceles in Papua New Guinea

Frontal encephaloceles are common in Papua New Guinea (PNG). Seventeen cases collected over 7 years are reported. Eleven frontal (sincipital) encephaloceles were repaired successfully via an extracranial approach. One of these patients with a frontonasal encephalocele developed a recurrence following the extracranial approach, which was subsequently repaired intracranially. Three patients with small naso-ethmoidal encephaloceles were repaired intracranially via an extradural approach. The other three cases have not yet had surgical correction. Complex craniofacial surgery which corrects hypertelorism as well as the encephalocele is unavailable in the developing world. For the general surgeon in the developing world, the extracranial approach is recommended for the frontonasal encephaloceles, and the intracranial approach for the naso-ethmoidal and naso-orbital encephaloceles. Hydrocephalus and epilepsy have not developed in the patients.

One stage reconstruction of large oral mucocutaneous defects with double paddled pectoralis major myocutaneous flaps

Fifty-five double paddled flaps and five single paddled flaps were used to reconstruct large surgical defects in the oral cavity. There were no complications in 38 cases. Two patients died, one from diabetic ketoacidosis and the other after discharge with a possible pulmonary embolus. One flap necrosed completely due to technical error and required a latissimus dorsi flap. The most frequent complication was intra-oral dehiscence in 12 patients, six of whom developed oral fistula. Following debridement the wounds healed spontaneously without further reconstructive surgery. In the developing world the double paddled pectoralis major flap allows a one stage operation that provides bulk for large defects in the cheek with two epithelial surfaces and the donor site can be concealed by clothes. Oral feeds can normally be started from the third day and this is particularly important where sophisticated nutritional support is not available.