The First Comprehensive Evaluation of Immuno-Inflammatory Markers for Prognosis in Esophageal Cancer Patients: A South Asian Perspective.

Background: Esophageal cancer (EC) remains a significant health challenge in South Asia, with poor prognosis despite advancements in diagnostics and treatment. Identifying and validating prognostic factors is essential for improving patient outcomes. Methods: A prospective study was conducted with 146 biopsy-confirmed EC patients at the Dr. Ruth K.M. Pfau Civil Hospital, Karachi, Pakistan. Clinical and laboratory data were collected and analyzed using descriptive statistics, receiver operating characteristic (ROC) analysis, and the Chi-square test. Survival outcomes were assessed using Kaplan-Meier curves, log-rank tests, and Cox proportional hazard models for univariate and multivariate regression analyses, with statistical significance set at p ≤ 0.05. Results: Bivariate analysis showed significant associations of the neutrophil lymphocyte ratio (NLR) (p = 0.017), C-reactive protein to albumin ratio (CAR) (p = 0.033), red cell distribution width to platelet ratio (RPR) (p = 0.020), and systemic immune-Inflammation index (SII) (p = 0.009) with patient survival. Univariate analysis identified tumor length >10 cm (p = 0.016), T4 stage (p = 0.015), metastasis (p < 0.001), surgery not performed (p < 0.001), and SII (p = 0.022) as significant factors for survival, with higher SII linked to poorer overall survival (p = 0.020). Interestingly, in the multivariate model, only metastasis (p < 0.001) and surgery not performed (p = 0.011) remained significant. Conclusions: Immuno-inflammatory markers may be less pertinent prognostic factors for EC in the South Asian population.

Correlation of inflammatory indices with staging of esophageal carcinoma: A prospective study at Dr. Ruth K. M. Pfau Civil Hospital, Karachi.

Objectives: To determine the correlation between inflammatory indices and the Tumour-Node-Metastasis stage of oesophageal carcinoma. METHODS: The prospective study was conducted from January 2021 to January 2023 at the Department of Upper Gastrointestinal Surgery, Dr Ruth K.M. Pfau Civil Hospital, Karachi, and comprised patients of either gender aged 18- 60 years with biopsy-proven oesophageal cancer. Blood samples were drawn and on the basis of plasma obtained, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, C-reactive protein-to-albumin ratio, lymphocyte-tomonocyte ratio and platelet-to red cell distribution width ratio were calculated. Modified Glasgow Prognostic Score was calculated on the basis of C-reactive protein and albumin levels. Values were compared with tumour length, depth of invasion, lymph node status, vascular involvement, metastasis, pathological subtype and grade of differentiation. Data was analysed using SPSS 24. RESULTS: Of the 220 patients aged 46.1±14.2 years, 120(54%) were females and 100(46%) were males. C-reactive protein-to-albumin ratio demonstrated the highest predictive power for advanced disease stage (p=0.003). Elevated neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio (p=0.010 and p=0.044) were positively correlated with node stage, while elevated platelet-to-lymphocyte ratio was associated with advanced clinical stage (p=0.046). C-reactive protein-to-albumin ratio exhibited positive association with higher tumour stage (p=0.033), node stage (p<0.001) and clinical stage IV (p<0.001). Modified Glasgow Prognostic Score was significantly associated with advanced clinical stage (p<0.001). Conclusion: Neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, C-reactive protein-to-albumin ratio, and Modified Glasgow Prognostic Score could be used effectively as a predictor of advanced oesophageal cancer.

Colorectal Cancer Survival and Its Prognostic Factors in Karachi, Pakistan.

OBJECTIVE: To determine the survival rates of colorectal cancer (CRC) in the Pakistani population and determine the prognostic factors for survival among the CRC patients. STUDY DESIGN: Retrospective cohort study. Place and Duration of the Study: The cancer registry of the Aga Khan University Hospital, Karachi, Pakistan, from 2010 to 2016. METHODOLOGY: The abstracted data from the cancer registry was cleaned and updated regarding the vital status at the last follow-up. Survival analyses were performed using the Kaplan-Meier method. Adjusted hazard ratios (aHR) and their 95% confidence intervals (CIs) were estimated using a cox regression model to assess the prognostic factors for survival. RESULTS: The overall proportion of late-onset CRC (>50 years of age) was 55.3% and early-onset CRC (<=50 years of age) was higher than expected (45.7%). A high level of carcinoembryonic antigen (CEA) (>5 ng/ml) was associated with poor survival compared to patients with CEA levels of ≤5 ng/ml (aHR = 1.68, 95% CI = 1.04, 2.72). Patients, who experienced recurrence, showed poorer survival (aHR = 4.27, 95% CI = 2.55, 7.14). Patients, who did not undergo surgery, showed significantly poorer survival compared to those who underwent surgery (aHR = 5.53, 95% CI = 2.35, 13.03). CONCLUSION: The findings suggest that monitoring CEA levels, ensuring prompt surgical treatment and follow-up care for recurrent cases can improve survival outcomes in patients with colorectal cancer. KEY WORDS: Colorectal cancer (CRC), Surgery, Recurrence, Grade, Cancer registry.

Esophageal cancer patient survival: A retrospective study from a tertiary care hospital in Pakistan.

Objective: To determine the pattern, tumor characteristics of esophageal cancer (EC) and survival of esophageal carcinoma patients presenting to upper GI Unit at Dr. Ruth K.M. Pfau Civil Hospital Karachi. Methods: We conducted a retrospective analysis of histologically confirmed EC patients from 2016 to 2021 at Upper GI Unit - Dr. Ruth K.M. Pfau Civil Hospital, Karachi. Data were collected using a filled Proforma, medical records, pathology reports and surgical notes, and patients or their family members were contacted for informed consent. Statistical analyses were performed using STATA version 16.0. Time to event was measured from the date of diagnosis to the date of the last follow-up or recorded death. Descriptive statistics and survival analyses, including Kaplan-Meier method and log-rank test, were employed. Univariate and multivariate Cox regression analyses were conducted to assess independent predictors of survival. Results: Total 152 patients with a median age of 45 (range 80-15) years were enrolled in this study. Clinical stages-III, IV-A and IV-B were identified in 35.5% (n = 54), 23.7% (n = 36) and 34.2% (n = 52), respectively. Total of 62% (n=94) had died at median follow up of 9.56 months and three years overall survival rate was 10.0%. Univariate survival analysis revealed that patients with clinical stage-II (p-value 0.002) and patients treated with combined surgery plus chemo-radiotherapy (p-value 0.040) was significantly associated with lower risk of mortality among other stages and treatment modality groups. Conversely, patients having metastasis (p value <0.001) and those with vascular involvement >90 degrees (p value <0.001) showed worse survival outcomes. Conclusion: Our study reveals a three years survival rate of 10.0%, emphasizing the formidable challenge of advanced-stage malignancies. Clinical stage, vascular involvement, and metastasis emerged as significant predictors of mortality. Moreover, integrating surgery with chemo-radiotherapy significantly improved three years survival (36.8% vs. 14.2%). Despite single-center limitations, our findings provide crucial regional insights into esophageal carcinoma outcomes.

Arterial involvement of lower limbs in peripheral artery disease - the difference between diabetics and non-diabetics.

OBJECTIVE: To detect peripheral artery disease in diabetic and non-diabetic individuals. METHODS: The case-control study was conducted from October 2018 to September 2019 at Ruth K.M. Pfau Civil Hospital, Karachi, and comprised diagnosed diabetic patients with random blood sugar ≥200mg/dl in group A, and healthy non-diabetic subjects in group B. Ankle brachial pressure index was measured and mean luminal diameters of lower limb arteries were compared using colour Doppler ultrasonography. Data was analysed using SPSS 21. RESULTS: Of the 82 subjects, 41(50%) were in each of the 2 groups. The sample had 42(51.2%) males and 30(48.8%) females with overall mean age of 53.9±5.07 years (range 44-60 years). There was significant difference in the ankle brachial pressure index values between the groups (p=0.004). There was also a significant difference in the mean luminal diameters of distal arteries (p=0.001), while there was no significant difference in proximal arteries (p>0.05). CONCLUSIONS: The diabetics were more prone to developing peripheral arterial disease than nondiabetics.

Three-staged minimally invasive esophagectomy with end-to-end esophago-gastric anastomosis for thoracic esophageal cancers: An experience from a low middle-income country.

BACKGROUND: Esophageal cancer is on a steady rise and carries significant mortality and morbidity. Depending upon the clinical stage at presentation, either chemotherapy, radiotherapy with or without surgical resection is the treatments in practice. Traditionally, open esophagectomy was performed but over time, the importance of minimally invasive esophagectomy has been established. In this study, we aimed to report our data of totally minimally invasive esophagectomies performed for thoracic esophageal cancers in last four years. METHODOLOGY: A prospective cross-sectional study was conducted at the Department of Upper GI Surgery, Dow University of Health Sciences, Karachi. All diagnosed cases of esophageal carcinoma undergoing minimally invasive esophagectomy, from 2019 to 2022 were included in this study. Outcomes measured were operative time, intra operative complications, conversion rate to open, postoperative complications, number of lymph nodes harvested, margin clearance, in-hospital mortality and 90-days mortality. RESULTS: A total of 53 cases were included in the study, the most prevalent histological type was squamous cell carcinoma 42(79.2%) as compared to adenocarcinoma 8(15.1%). Most common tumor site was lower thoracic esophagus (30-38 cm) in 20 (56.6%) cases. Neo-adjuvant chemotherapy was given in all 53(100%) cases, whereas neo-adjuvant radiation therapy was offered to 49(92.5%) patients. There was a significant and favorable patient response to the neo-adjuvant treatment in 37(69.8%) cases, leading to a decrease in tumor size. Laparoscopic McKeown Esophagectomies were performed in 44 (83.0%) and 9(17.0%) were Robot-assisted Minimally Invasive esophagectomy (RAMIE). Intraoperative injuries (i.e., lung parenchymal injury and bleeding) were reported in only 2(3.8%) patients. Post-operative complications were recorded in 12(22.6%) patients. Margin clearance was observed in 53 (100%) of the patients. The 90-day mortality rate was 3(5.7%), one due to bleeding and other two mortalities were due to COVID related respiratory complications. CONCLUSION: Minimally invasive esophagectomy was found to be safe and feasible technique with encouraging results in terms of decreased intraoperative and post operative complications as well as achieving the standard oncological surgery with acceptable lymph node yield and margin clearance and in hospital and 90 days mortality.

Frequency of Nonalcoholic fatty pancreatic disease in patients with carcinoma pancreas presenting for upper abdominal Endoscopic Ultrasound in a tertiary care center.

OBJECTIVE: To determine the frequency of nonalcoholic fatty pancreatic disease in patients with carcinoma pancreas presenting for upper abdominal endoscopic ultrasound. METHODS: The prospective cross-sectional study was conducted in the Endoscopy Suite of Surgical Unit 4, Civil Hospital, Karachi, from October 2019 to September 2020, and comprised patients presenting for endoscopic ultrasound. Patients were divided into Group A comprising carcinoma pancreas patients, and Group B having non-carcinoma pancreas patients. Fatty pancreas was identified by hyperechogenicity on endoscopic ultrasound. Data was analysed using SPSS 19. RESULTS: Of the 68 patients, 44(64.7%) were male and 24(35.3%) were females. The overall mean age was 49.9±13.82 years (range: 16-80 years). There were 35(51.5%) patients in Group A and 33(48.5%) in Group B. The frequency of nonalcoholic fatty pancreatic disease was 18(26.5%) and 15(83.3%) of them were male subjects (p=0.04). Group A had 12(34.28%) subjects with nonalcoholic fatty pancreatic disease compared to 6(18%) in Group B (p=0.11). CONCLUSIONS: Nonalcoholic fatty pancreatic disease was frequently seen in carcinoma pancreas patients undergoing endoscopic ultrasound compared to non-carcinoma pancreas patients. Most of the patients affected were males.

Ascaris induced acute pancreatitis in paediatric population - a case series.

The most common helminthic parasitic infection inhabiting human intestine is Ascaris lumbricoides (AL). Being the largest of the helminthic family, it infects almost one billion people worldwide, but any information about local population is unavailable especially in children. When patients present with abdominal pain, having ascaris induced pancreatitis never meets the differential diagnosis list even though AL itself is highly prevalent in our part of the world. Infected patients can present with a variety of symptoms depending on the location of parasite. If the biliary tree is inhabited, patients usually present with symptoms of choledocholithiasis or pancreatitis. We report the case series of 3 patients from paediatric age group, having acute pancreatitis secondary to AL. Patients had upper abdominal pain of varying duration. Ultrasound abdomen showed worm inside the Common Bile Duct (CBD) in all 3 patients. Endoscopic retrograde cholangio-pancreatography (ERCP) showed worms coming out of the ampullary orifice. Two patients received albendazole orally post ERCP and were discharged after complete resolution of symptoms with advice of repeat ERCP after 6 weeks, however one patient was advised Magnetic resonance cholangio-pancreatography (MRCP).

Is laparoscopic experience helpful in simulator based robotic training in general surgery?

OBJECTIVE: To evaluate whether or not prior laparoscopic training improves performance during robotic surgery utilising DaVinci robotic skills simulator. METHODS: The cross-sectional study was conducted at the Civil Hospital, Karachi, from May 4 to November 11, 2018, and comprised first year residents in Group A with no laparoscopic skills and fourth year residents doing laparoscopic cholecystectomy independently and surgical faculty members in Group B who had laparoscopic skills. Both the groups had no previous exposure to robotic surgery and skills simulator. There were 4 exercises which were repeated three times by each participant. Scoring was done using the DaVinci robotic skills simulator software. Data was analysed using SPSS 22. RESULTS: Of the 30 surgeons, there were 15(50%) in Group A with a mean age of 26±0.56 years, and 15(50%) in Group B with a mean age of 32 ± 9.16 Years (p<0.001). The overall mean age was 32±9.16 years (range: 25-52 years). There were 19(63.3) females in the sample compared to 11(36.6%) males. Mean scores of Ring walk 2, Peg board 2, and Suture sponge 3 were better in Group A, while mean score of Matchboard 2 was better in Group although B (p>0.05). Group B fared better in the individual scoring of Suture sponge 2 (p>0.05). CONCLUSIONS: Laparoscopic skills apparently did not confer any benefit while performing exercises on the DaVinci skills simulator.

Effectiveness of educational intervention in raising knowledge regarding breast cancer among female nurses.

OBJECTIVE: To assess the effect of nursing educational session on nurses' knowledge level related to breast cancer. METHODS: The quasi-experimental study was conducted at the Dow University of Health Sciences, and the Dr. Ruth Pfau Civil Hospital, Karachi, from January to July 2018, and comprised nurses from two tertiary care hospitals. A single educational session lasting 90-120-minute was conducted for all the subjects. Knowledge level was tested at baseline and post-intervention using the Comprehensive Breast Cancer Knowledge Test questionnaire. Data was analysed using SPSS 20. RESULTS: There were 131 nurses with a mean age of 31.05±6.23 years (range: 18-47 years). Overall, 53(40.5%) subjects had General Nursing Diploma; 92(70.2%) were married; 108(82.4%) had no history of breast cancer, 47(35.9%) had 1-4 years of working experience; and 106(80.9%) had completed their graduation from public-sector institutions. The improvement post-intervention was significant in all the three components of knowledge (p<0.05). CONCLUSIONS: Nursing educational session was found to have increased nurses' knowledge related to breast cancer.

A comparative follow up study of transabdominal preperitoneal mesh repair in inguinal hernias with or without mesh fixation.

OBJECTIVE: To compare the recurrence rate and chronic pain in hernia patients undergoing laparoscopic or robotic transabdominal preperitoneal fixation with and without mesh. METHODS: The prospective comparative study was conducted at Surgical Units 4 and 5 of the Civil Hospital, Karachi, from August 1, 2017, to July 1, 2018, and comprised hernia patients undergoing laparoscopic or robotic transabdominal preperitoneal fixation who were randomised into fixation Group A and non-fixation Group B. Postoperative visual analogue scale score was calculated at the time of discharge. At 1-year follow-up, recurrence rate and chronic pain were assessed. Data was analysed using SPSS 23. RESULTS: Of the 98 patients, there were 49(50%) in each of the two groups. Of the total, there were 97(99%) males. The overall mean age was 44.52±14.51 years. The differences in visual analogue scale scores at the time of discharge and the mean discharge from the hospital in terms of days were statistically significant (p<0.005). At 1-year follow-up, there was recurrence in 1(1.02%) case and that was in Group A (p>0.05). Chronic pain between the groups was not significant (p>0.05). CONCLUSION: There was no significant difference in terms of recurrence and chronic pain between mesh and non-mesh fixation.

Resolution of symptoms after Heller's cardiomyotomy with DOR fundoplication versus endoscopic balloon dilatation in patients with achalasia Cardia at tertiary care hospital.

OBJECTIVE: To compare improvement in symptoms following Heller's myotomy with Dor fundoplication and endoscopic pneumatic dilatation for the treatment of achalasia cardia. METHODS: The prospective comparative study was conducted at the Department of Upper Gastroenterology and Minimally Invasive Surgery, Civil Hospital, Karachi, from February 2016 to January 2019, and comprised patients diagnosed with achalasia cardia on oesophageal manometry. The subjects were randomised into endoscopic pneumatic dilatation group A and laparoscopic Heller's myotomy with Dor fundoplication group B. Eckardt scores were compared between the groups at one-year follow-up. Data was analysed using SPSS 22. RESULTS: Of the 42 patients, 21(50%) were in each of the two groups. The mean age of patients in group A was 37±12.87 years compared to 34±8.59 years in group B. Treatment success in group A was 11(52%) compared to 21(76%) in group B. Eckardt scores between the groups were significant (p<0.001). Patient satisfaction was significantly more in group B (p<0.05). CONCLUSIONS: The efficacy of Heller's myotomy with Dor fundoplication was found to be greater than endoscopic pneumatic dilatation for improvement in dysphagia and overall patient satisfaction at one-year follow-up.

Plastic stent migration in ERCP; a tertiary care experience.

OBJECTIVE: To evaluate the entire spectrum of endoscopic retrograde cholangiopancreatography procedure including site of stent migration, techniques of stent retrieval, success and complications. METHODS: The retrospective study was conducted at Dr Ruth Pfau Civil Hospital Karachi, and comprised data from January 2010 to January 2017of patients who underwent endoscopic retrograde cholangiopancreatography for the retrieval of stent migrated in the common bile duct, pancreatic duct or pancreatic pseudocyst or were found to have migrated stent during either stent removal or exchange and where attempts were made to remove the stent. A team of expert endoscopists had performed all the procedures. SPSS 17 was used for statistical analysis. RESULTS: There were 5700 procedures performed on 4800 patients. Pancreato-biliary stenting was done in 1229(21.56%) patients; 745(60.61%) with benign conditions and 484(39.38%) with malignant. Stent migration was found in 51(4.14%) patients; 30(58.8%) males and 21(41.2%) females. In terms of clinical presentation, right upper quadrant pain was the most common 9(17.6%). Technical success was achieved in all (100%) cases, with firstprocedure success in 45(88.2%). There was no complication or procedure-related mortality. CONCLUSIONS: In patients with stent migration, endoscopic retrograde cholangiopancreatography was found to be a safe and effective modality for stent retrieval.

Feasibility of robotic surgery in a developing country, a public sector Perspective.

OBJECTIVE: To assess the clinical feasibility of robotic platform and to calculate cost for sustaining it.. METHODS: The study was conducted at Sindh Government Qatar Hospital and Civil Hospital Karachi from October 11, 2011, to August 30, 2017. Feasibility was assessed in terms of clinical outcome i.e. surgical complications, duration of stay and readmissions. The cost of doing an individual procedure was calculated along with the projected cost for 150, 200 and 250 cases per year. SPSS 23 was used for data analysis.. RESULTS: Of the 119 patients, 45(37.8%) were males and 74(62.2%) were females. Overall mean age was 42.10}13.40 years (range: 21-80 years. Mean hospital stay was 3.59}3 (range: 1-19 days). Complications occurred in 17(14.3%) patients ranging from wound infection 7(5.9%), bleeding 5(4.2%), intra-abdominal abscess 3(2.5%) and recurrence 2(1.7%). The total cost of robotic platform was Rs320 million with an annual maintenance contract of 10% of the total cost. The mean cost of performing a robotic procedure was Rs.389,263.05}39,249.63 (range: Rs252,823.09- Rs456,842.79).. CONCLUSIONS: Robotic surgery was found to be a feasible and viable option. The major hindrance was the cost involved in setting up the system and recurring costs in terms of disposables.

Stented Pancreatico-duodenectomy: Does it lead to decreased pancreatic fistula rates? A prospective randomized study.

OBJECTIVE: To compare clinically relevant pancreatic fistula rates in patients with stented versus non-stented pancreatico-jejunostomies. METHODS: The randomised comparative clinical trial was conducted at Civil Hospital, Karachi, from September 2009 to August 2015, and comprised patients presenting to the Surgical Unit 4 with a diagnosis of resectable periampullary carcinoma, carcinoma of head of pancreas, duodenal carcinoma involving the second part, and distal cholangiocarcinomas. Pancreatic fistula or leakage was defined as amylase-rich fluid lasting over 5 days, collected from the peripancreatic drains on day 1, 3 and 7 postoperatively, and the rate of clinically relevant fistulas was taken as primary study endpoint. RESULTS: There were 102 patients with a male to female ratio of 2.4:1. The overall mean age was 53.16±12.11 years (range: 30-80 years). Of the total, 53(51.9%) patients had pancreatic duct stent and 49(48%) did not. Clinically relevant pancreatic leak was seen in 13(12.7%) patients of whom 8(61.5%) were stented (p=0.46), 9(69.2%) patients had soft pancreatic texture (p=0.54) and 7(53.8%) had pancreatic duct <3mm (p=0.11). CONCLUSIONS: Pancreatic fistula rates between stented and non-stented anastomosis did not show any significant difference.

Pancreas Divisum.

OBJECTIVE: To evaluate the complications, technical success, diagnostic evaluation and various endoscopic management options in patients with pancreas divisum. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Endoscopy Suite, Surgical Unit 4, Civil Hospital, Karachi, from January 2007 to December 2013. METHODOLOGY: All Endoscopic Retrograde Cholangio-pancreatography (ERCPs) procedure performed in patients with pancreas divisum were analyzed. Success was defined as having authentic diagnostic information or a successful endoscopic therapy for the condition. RESULTS: During the study period, 3600 patients underwent 4500 ERCPprocedures. Pancreas divisum was found in 17 patients (0.47%); 7 ERCPs (41.2%) were performed for diagnostic and 10 (58.8%) for therapeutic purposes. Sixteen (94.1%) had complete PD and one (5.9%) had incomplete PD. Male and Female ratio was 1:1.83 with a mean age of 26.3 years and median symptom duration of 11 months. Atotal of 23 procedures were performed in 17 patients; 2 had ERCP done thrice, 2 underwent the procedure twice, while the rest had single procedure done. Six (35.3%) patients had chronic pancreatitis, 7 (41.2%) had acute recurrent pancreatitis and 4 (23.5%) had acute pancreatitis. Endoscopic minor papillotomy was performed. There was no procedure-related mortality. ERCPaffected management in 88.2% (15/17 procedures). CONCLUSION: ERCPis a safe and feasible procedure for pancreas divisum patients.

Results of level-II oncoplasty in breast cancer patients: an early experience from a tertiary care hospital in Pakistan.

OBJECTIVE: To assess the oncologic and cosmetic outcomes for breast cancer patients who underwent breast conservation therapy using Level II oncoplasty techniques. METHODS: The prospective, non-randomised and descriptive study was conducted at the Department of Surgery, Unit IV of Civil Hospital, Karachi, from December 2009 to November 2011 in which 21 consecutive women with breast carcinoma who underwent wide local excision with remodeling mammoplasty were enrolled. All patients were reviewed by the surgeon and medical oncologist every 3 months for the first year. A grading system of 5-1 (excellent to poor) was employed and those with 3 or more were considered to have acceptable results. RESULTS: The mean patient age was 45.38 +/- 10.09 years (range: 26-70); 11 (52.3%) were premenopausal and 10 (47.7%) were postmenopausal; and 5 (27.8%) had family history of breast cancer. The mean size of the tumour determined by histology was 59.9 +/- 3.18 mm (range: 25-150). Eight (30%) patients received preoperative chemotherapy to downsize the tumour. Three (14.2%) patients received preoperative radiotherapy. Mean operative time was 1.59 +/- 0.52 hours (range: 1-2.5 hours). Mean volume of breast tissue excised from the breast containing the tumour was 545.27 +/- 412.06 cm3 (range: 43.70-1456). Assessment of excision margins showed no tumour at the margins of 19 (90.4%) patients. Two (9.5%) patients had close but negative margins. The mean hospital stay was 7.10 +/- 3.30 days (range: 4-15). There were early complications in 4 (19%) patients. One (4.76%) patient had late complications. Two (9.5%) patients developed tumour recurrence; both had an ipsilateral tumour recurrence. None of the patients developed metastases and one died of cardiac problem. Twenty (95.2%) patients had an acceptable post-surgical cosmetic result. CONCLUSION: Level II oncoplasty was a safe option in breast conservation allowing large-sized and difficult-location tumour excision with good cosmetic outcome in the study group. There is a need to increase the awareness and acceptance of this new technique not only amongst patients but also doctors.

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.

Frequency and risk factors in the post-ERCP pancreatitis in a tertiary care centre.

OBJECTIVE: To evaluate the frequency and associated factors in the post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. STUDY DESIGN: Cross-sectional analytical study. PLACE AND DURATION OF STUDY: Endoscopy Suite of Surgical Unit IV, Civil Hospital, Karachi, from December 2009 to November 2010. METHODOLOGY: Patients undergoing ERCP were included. Patients who had presented with pancreatitis or raised amylase levels before procedure or patients who had previous history of surgery on the biliary or pancreatic systems were excluded from the study. Pearson chi-square and Fisher's exact test were used for qualitative data and t-test for quantitative data. Significance was taken as p ² 0.05. Odds ratio was calculated for the qualitative data using 95% confidence interval. RESULTS: Age of the study population ranged from 9 to 90 years (mean age 46.5 ± 14.94 years, median 45 years). Male to female ratio was 1:1.87. Pancreatitis was seen in 18 patients (3.6%), mild in 15 (3%), moderate in one (0.2%) and severe in 2 (0.4%). Mean amylase level at 4 hours and 24 hours was 280.93 ± 539.13 and 168.83 ± 338.34 respectively. Pancreatitis was seen in 15/326 (4.6%) females and 3/174 (1.72%) males. Statistically significant increased risk for pancreatitis was seen in difficult cannulation (9.8%, p = 0.006), prolonged cannulation time (7.6 minute, p = 0.002), pancreatic duct cannulation (13.7%, p = 0.001) and pancreatic duct contrast injection (13.4%, p < 0.001). CONCLUSION: The frequency of post-ERCP pancreatitis was 3.6%. Difficult cannulation, pancreatic duct cannulation, pancreatic duct contrast injection and balloon sphincteroplasty were associated with higher frequency of post-ERCP pancreatitis. Reuse of ERCP accessories poses no additional risk to the frequency of pancreatitis.

Endoscopic management of post operative bile duct injuries.

OBJECTIVE: To evaluate the pattern of post-operative bile duct injuries and their subsequent endoscopic management. METHODS: The prospective, non-randomised, cross-sectional study was conducted at the endoscopic suite of Surgical Unit-IV of the Civil Hospital, Karachi, over a period of three years. A total of 97 patients were included in the study. Post-procedure patients were followed up for resolution of symptoms and cessation of the bile leak. Patients with complete biliary cutoff or transection on Endoscopic Retrograde Cholaugio-Paucreatography (ERCP) were advised Magnetic Resonance Cholaugio-Papereatography (MRCP). Average followup of patients in our study was for 3 months. Mann Whitney U test was applied for non-parameteric data. RESULTS: Out of 97 patients in the study, 82 (84.5%) presented with post-operative bile leakage and 15 (15.5%) with obstructive jaundice. The age of the study population ranged between 20-70 years with a mean age of 40.80 +/- 13.45 years. Male-to-female ratio was 1:3. ERCP findings in our study included 41 (42.26%) patients with bile leakage out of which 27 (27.8%) had high-grade leak and 5 (5.1%) had low-grade leak, while 9 (9.3%) patients had Common Bile Duct (CBD) stones. Among the patients, 39 (40.2%) had complete cutoff of CBD. There were 15 patients with strictures and 6 with normal ERCP. As for the bile leads, 36/41 (87.8%) patients were managed successfully by endoscopic stenting, stone removal or simple sphincterotomy. Of the 41 patients, 5 (12.2%) with bile leak developed biliary stricture on subsequent ERCP. Nine of the 15 patients (60%) with complete cutoff on initial endoscopy were successfully stented on subsequent ERCP after demonstration of biliary continuity on MRCP. Six (40%) patients were referred for surgery. CONCLUSION: Patients with postoperative biliary leaks fare much better than those with complete cutoff or strictures. MRCP should be done in all patients where ERCP shows loss of biliary continuity. Re-exploration should be deferred till all other non-invasive modalities have been tried.