Malignant pyloro-duodenal obstruction: role of self expandable metallic stents.

OBJECTIVE: To determine the outcome of duodenal stenting in palliation of patients with malignant pyloric and duodenal obstruction. METHODS: The non-randomised prospective descriptive study was conducted at the Endoscopy Suite, Surgical Unit-IV, Civil Hospital, Karachi, from December 2007 to November 2010. All patients presenting with inoperable ampullary, pancreatic or biliary cancers causing duodenal obstruction and patients with resectable malignancy but unfit for surgery were included. The procedure was carried out by a single expert endoscopist under local or general anaesthaesia as required. Boston Scientific stents of variable sizes were used. Follow-up was done at 1 week, 1 month and 6 months. Data analysis was done using SPSS 15. RESULTS: Over the study period, 159 (60%) males and 6 (40%) females were included in the study. The male-to-female ratio was 2:3. The overall age ranged from 25-80 years with a mean of 52.67 +/- 15.07 years. Primary diagnosis was pyloric carcinoma in 7(46.6%), carcinoma Gallbladder in 4(26.6%), Duodenal carcinoma in 3(20%) and carcinoma head of pancreas in 1(6.6%). Relief of symptoms were seen in 11 (73.3%), while complications were seen in 2 (13.3%). Stents were inserted with technical success in 14 (93%) patients. Clinical success was seen in 11 (73%), with a mean survival of 74.27 +/- 40.7 days (range: 15-180 days). No statistical significance was found when comparing the survival time with age, gender and diagnosis. CONCLUSION: Use of self-expandable metallic stents for gastroduodenal malignancies appears to be a feasible, safe and effective method, especially in those patients with limited life expectancy.

Experience of thymectomy by median sternotomy in patients with myasthenia gravis.

OBJECTIVE: To determine the outcome of thymectomy in patients with myasthenia gravis and safety of median sternotomy approach. METHODOLOGY: An observational descriptive study was conducted in the department of thoracic surgery JPMC from February 2005 to January 2009. Twenty-two patients having persistent generalized or ocular myasthenia gravis referred to our department by neurologists and general physicians, partially or not responding to medical treatment with or without thymoma, were included in the study. Those who were not fit for anaesthesia were excluded. Preoperatively 2 to 3 sessions of plasmapheresis were done and each patient was given anti myasthenia gravis treatment. Clinical staging was done by Modified Osserman classification. Median sternotomy approach was used. Outcome was assessed on the basis of remission of disease in different Osserman groups. All patients were followed for a minimum of 6 months. RESULTS: Out of 22 patients, 16 (72.7%) were females and 6 (27.2%) males. Mean age at presentation was 35.2 +/- 14.5 years. Mean duration of symptoms was 1.5 +/- 1.2 years. A total of 4 (18.1%) patients with myasthenia gravis had thymoma and histopathology of 18 (81.9%) patients showed thymic hyperplasia. Remission was seen in most grades of Osserman. The best response was seen in Grade I where all patients achieved remission. Most patients in Grade II A and II B were benefited. The only patient in Grade III had no improvement of symptoms. No patient in Grade IV underwent thymectomy. Overall 86.3% had a positive outcome on basis of remission and improvement. CONCLUSION: Thymectomy by median sternotomy is safe and effective with more favourable outcomes for patients of myasthenia gravis not responding to medical treatment.