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Rare surgeries

MAXILLARY OSTEOTOMY IN SICKLE CELL ANEAMIC Patient
Before Surgery

I never thought I would come across a sickler patient for osteotomy when studied BDs days it is supposed to be one of those topic for Madams, tp pester us in viva only . 8 months ago I had an28 yr old Omani national who think he is not getting alliance because of his gummy smile .He is desperate to get it corrected . He is unable to get it done in Oman for various reasons. I told him we will do it here . send for pre-aneathtic check up anesthetist said no probs but to get hematology clearance.

Heamatolgist advised long battery blood tests to starts with electrophorses test to quantify the percentage of HBs (sickle Hb) Then only I knew that there are different grades in sickle cell disease depending on the percentage of HbS with Hb A if it is less than 30 % you can go ahead without any optimization this pts Hbs was nearly 40 %. He suggested this pt requires exchange transfusion means you have to remove two units of pt blood and transfuse with one unit of fresh blood and repeat the test until ur Hbs is optimum Arabi agreed . We scheduled the surgery send him for exchange transfusion to heamatology dept in another hospital they want Rs 2 lakhs for above procedure. Total fee for surgery we agreed was around 1 lakhs he got furious and came back without transfusion surgery got cancelled He said he will do the transfusion an Oman and do the surgery here to add my head ache the window period is max one week after transfusion to do the surgery I gave referral letter to hematologist in oman and send him back I thought good riddance. After couple of months to my surprise he contacted me with whatts app he has arranged exchange transfusion he will come after two weeks my anesthetist were not fully happy . I showed the post transfusion HbS to our hematologist it was only slightly better than before the hematologist in oman said further correction is not possible. they warned about to avoid hypoxia and avoid hyperviscosity of blood
We posted surgery on the same day he arrived from Oman HbA was 10%. During intubation unexpected complication he is a mouth breather due to adenoids won,t allow to pass nasal tube and cause severe bleeding & very difficult insert the tube and cause heavy bleeding and airway compromise our aneathetist tried twice but due to bleeding he stopped we (Myself & Ajay)were thinking of Teachostomy I am sure that the bystanders won’t agree. Or submental intubation but chances of patient going to hypoxia is high when we were debating ourselves our whole aneasthetic team tried with smaller tubes and gone through luckily
Osteotomy was smooth may be due to hyperactive marrow bone were very soft and bloody we did le fort 1 osteotomywith AMO in short time actually genioplasty was also needed but we did’t do.
Post op Hb% was 7.5 we transfused two units of fresh blood otherwise surgery was uneventful. Patient was discharged on third day he left the country after one week .He came back after 7 months for debonding Happy man.
After surgery

Surgical correction of a facial vascular deformity causing a massive tongue & lips which was not only a facial deformity but also a significant functional disability to a 42 yr old man. Many previous attempts of surgical correction were failed elsewhere. This surgery was carried out through an innovative surgical technique using harmonic scalpel, which was later published in American journal of Oral & Maxillofacial surgery Feb 2010

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Surgical removal of a massive tumour (1Kg) from a 14 yr old poor girl’s mouth which was not only causing severe facial deformity but also affecting her normal eating & speech. It also caused many incidences of life threatening airway problems for her for last 4 yrs.

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