Breast Cancer Management Consensus By The Society of Surgeons and Surgical Oncology Society of Pakistan.

The Society of Surgeons of Pakistan and The Society of Surgical Oncology of Pakistan with factions from various major centres comprising of surgical oncology, medical and radiation oncology collaborated to reach consensus on breast cancer management guidelines and a framework of "good practice" minimum standards of care. The aim of the task force was to enhance treatment standards, which have a direct correlation with improving patient mortality and morbidity and long-term survival whilst taking into consideration economic limitations of access to leading centers of excellence as well as minimum expertise required in health care. These multidisciplinary guidelines, whilst not exhaustive, aim to provide an algorithm of care for breast cancer patients at tertiary care centres and district level hospitals to provide most appropriate treatment.

Role of Chewing Gum in Reducing Postoperative Ileus after Reversal of Ileostomy: A Randomized Controlled Trial.

BACKGROUND: Postoperative ileus is one of the most prevalent and troublesome problems after any elective or emergency laparotomy. Gum chewing has emerged as a new and simple modality for decreasing postoperative ileus. The aim of this study was to determine the effectiveness of chewing gum in reducing postoperative ileus in terms of passage of flatus and total length of hospital stay. PATIENTS AND METHODS: This single-blinded, randomized clinical trial was conducted in department of surgery, Services Hospital Lahore, between November 2013 and November 2015. The patients were divided into two groups: chewing gum (Group A) and no chewing gum (Group B). Starting 6 h after the operation, Group A patients were asked to chew gum for 30 min every 8 h; bowel sounds, passage of flatus and total length of hospital stay were noted. Outcome measures such as passage of flatus and total length of hospital stay in patients undergoing reversal of ileostomy were compared using t-test. RESULTS: Mean age of the patients in Group A was 26.12 (± 7.1) years and in Group B was 28.80 (± 10.5) years. There were 25 males (50%) and 25 females (50%) in Group A. In Group B, there were 29 males (58%) and 21 females (42%). Mean BMI in Group A was 23.5 (± 5.3), and in Group B was 21.4 (± 4.6). The mean time to pass flatus was noted to be significantly shorter, 18.36 (± 8.43) hours, in the chewing group (Group A), whereas in the no chewing gum group (Group B), it was 41.16 (± 6.14) hours (p value < 0.001). The mean length of hospital stay was significantly shorter 84 (± 8.3) hours in the chewing gum group (Group A) as compared to 107.04 (± 6.4) hours in the no chewing gum group (Group B) (p value 0.000). CONCLUSION: It is concluded that postoperative chewing of gum after the reversal of ileostomy is accompanied with a significantly shorter time to passage of flatus and shorter length of hospital stay.

Giant lipoma of submandibular region; an unusual presentation.

Lipomas in the submandibular region are very uncommon. Large submandibular neck mass (greater than 10 cm) with a rapid growth rate, may raise concern about possible malignancy of salivary glands. Failure to distinguish salivary gland tumour and liposarcoma from a lipoma may represent a medico-legal pitfall. It is very important for the surgeon to rule out liposarcomas when dealing with giant lipomas in such regions. We report a case of a 65-year-old male who presented in the OPD with complains of pain and a 15x12 cm, giant submandibular solitary lipoma of anterior neck which had rapidly increased in size. The diagnosis of lipoma was confirmed on physical examination, radiological investigations and Fine Needle Aspiration Cytology (FNAC). The Patient underwent surgical excision. The surgery produced excellent cosmetic results and no functional impairment. This study illustrates the literature regarding aetiology, epidemiology, followed by diagnostic and treatment modalities of submandibular lipomas.

Clinical Practice Guidelines For The Management Of Colorectal Cancer, A Consensus Statement By The Society Of Surgeons® And Surgical Oncology Society Of Pakistan®.

A joint effort by the Society of Surgeons Pakistan and Society of Surgical Oncology Pakistan, these guidelines provide a framework for the practicing surgeons involved in care and management of patients with colorectal cancer. The guidelines take into account the issues related to our local circumstances and provide a minimum standard of care that must be given to these patients. The Guideline Committee had members from all disciplines, including surgery, surgical oncology, medical oncology and radiation oncology. The guidelines have attempted to simplify things to understand and follow for the practicing surgeons. With these guidelines we wish to eliminate disparities in treatment among institutions and prevent any under treatment of patients.

Pancreaticoduodenectomy: Outcomes of a complex surgical procedure from a developing country.

BACKGROUND: Pancreaticoduodenectomy (PD) plays an integral part in the management of pancreatic, periampullary and duodenal cancers, along with a few other pathologies of this region. Despite advances in surgery PD continues to have significant morbidity and noteworthy mortality. The aim of this study is to provide an in-depth report on the patient characteristics, indications and the outcomes of PD) in a tertiary cancer hospital in Pakistan. MATERIALS AND METHODS: The study population included patients who underwent PD between January 1, 2014 and march 31, 2019, at Shaukat Khanum Memorial Cancer Hospital and Research Center (SKMCH&RC) in Pakistan. The data was retrospectively analyzed from the Hospital Information System (HIS), which is a prospectively maintained patient electronic database of SKMCH&RC. Patient characteristics, procedural details and post-operative outcomes according to internationally accepted definitions were reported. RESULTS: A total of 161 patients underwent PD at our hospital in the study period at a median age of 53 years, ranging from 19 to 78 years. 62% of the patients were males while 37% were females. Jaundice was the most common presenting symptom (64.6%), followed by abdominal pain (26.7%). PD with pancreaticogastrostomy was performed in 110 patients (68.3%), while pancreaticojejunostomy was performed in the rest of the cohort. Surgical site infection (SSI) was observed in 64 patients (40%). The incidence of Pancreatic Fistula grade C based on the International Study Group on Pancreatic Fistula (ISGPF) definition was 7.45% (n = 12). The 30 days mortality rate was 3.1%. Median survival of the cohort was 21 ±1.13 months and disease-free survival was 16±2.62 months. CONCLUSION: PD can be performed with acceptable morbidity and mortality in a resource constrained country, as long as it is undertaken in a high-volume center. This is in keeping with data published from other well-reputed international centers.

An interesting and rare case of traumatic oesophagocutaneous fistula.

Oesophagocutaneous fistula is a very rare disorder. No case of oesophagocutaneous fistula after blunt trauma has been reported. In this report we present a case of 25-year-old nursing student seen at the Lahore General Hospital, Lahore, with a history of blunt trauma to the neck. She was initially diagnosed with supra-sternal abscess. A few days after the incision and drainage of this abscess, she developed discharge of water and food particles from the wound site. It was investigated and diagnosed as oesophagocutaneous fistula. Her neck exploration was done and fistulous tract was found communicating with the upper mid-esophagus. The tract was excised and sent for biopsy. Histopathology revealed non- caseating granulomas with no evidence of malignancy. A gene X-pert was done to rule out tuberculosis and it came out to be negative. Postoperatively, the patient is living a normal life. This is the first of its kind case of oesophagocutaneous fistula reported from our part of the world.

The spectrum of injuries from motorcycle induced road traffic accidents from level one trauma center: A prospective observational study.

OBJECTIVE: To observe the role of motorcycles in causing Road Traffic Accidents and assess the demographics of the drivers, the injury patterns and their outcomes. METHODS: This prospective observational study was conducted at the Surgical Unit 1, Lahore General Hospital, Lahore for a period of 6 months from November 2017 to May 2018. All patients presenting in ER with RTA secondary to motorcycle trauma were included in the study. Data of patients including demographic and medical data, helmet use, spectrum of injuries, specific injury diagnosis, and final disposition of patients was analyzed. The distribution and associations of both victim- and crash-related variables such as crash mechanism, types of involved vehicles, types of injuries, and demographic characteristics were investigated. Data were analyzed by SPSS v23. RESULTS: A total of 835 patients were included in this study with 685 (82%) being male (mean age 28.38 ± 13.89 years) and775 (92.7%) were motorcycle users. The majority of road traffic crashes, traffic accident's mechanism were motorcycle-vehicle accident 579 (69.3%), followed by collision with slow moving carts and bicycles 104 (12.5%). Inner city main roads were the site for 563 (67.4%) accidents. Only 168 (2.2%) patients were wearing helmets at the time of trauma. CONCLUSIONS: Motorcycle traffic morbidities and mortalities remain to be a major public health issue in Lahore as well as all over Pakistan. There is an urgent need for an efficacious interventional programs to decline the burden of motorcycle related morbidity and mortalities.

Management of parathyroid adenoma: An institutional review.

To assess indications, role of preoperative localization, intra-operative details and post operative recovery of patients who underwent parathyroidectomy. Data of adult patients diagnosed with parathyroid adenoma with primary hyperparathyroidism from January 2006 to September 2016 was retrieved from medical records. Demographics, preoperative investigations, operative details and follow up were studied. Seventeen patients diagnosed with primary hyperparathyroidism (PHPT) due to parathyroid adenoma, were managed by parathyroidectomy by skin collar incision. Median age was 46 (IQR 35 - 57). Median duration of surgery was 80min (IQR of 15-120 min) and median blood loss was 15ml. Thyroid nodules were observed in three patients, which were managed by thyroid lobectomy. Preoperative Sestamibi scan localized adenoma in 14 patients (frequency 82%). Intraoperative methylene blue and endoscopic ultrasound were not used. Parathormone (PTH) and calcium level were decreased in all post operative patients except one and no recurrence was seen on follow up. Parathyroid adenomas can be successfully localized with a pre-operative Sestamibi scan. Surgery remains the mainstay of treatment.

Short term surgical outcomes of Wilms tumour from a single institute.

Wilms tumour is the commonest solid tumour of childhood in Pakistan. In developed world the long-term outcome of Wilms tumour have significantly improved reaching up to 98% long term survival. We have no National data of prevalence, treatment and survival of this condition in Pakistan. Surgical treatment also varies in various parts of the country. We have studied our patients presenting with a diagnosis of Wilms tumour to our institute from Jan 2014 to April 2016. A total of 42 patients were operated for Wilms tumour. The most common symptoms were abdominal mass (75%), pain (28%) and fever (19%). A total of 48 tumour resections were performed, 45 total nephrectomies and 3 had nephron sparing surgery (NSS). Mean operative time was 225±78.7 minutes. Mean blood loss was 165±223.5ml. Mean size of the tumour was 102±48.4mm and mean weight of the tumour was 433±400.7gm. Ninety percent patients had a favourable histology. Mean high dependency unit (HDU) stay was 1.16±1.2 day and mean hospital stay was 6.89±3.47 days. Complications were observed in 8 patients. Surgery remains a major part of treatment for Wilms tumour.

Laparoscopic Sleeve Gastrectomy - A Prospective Follow Up Of 30 Patients.

BACKGROUND: Morbid obesity has become a surgically treatable problem. Laparoscopic sleeve gastrectomy is becoming a popular choice both for surgeons and patients due to effectiveness and low complication rates. METHODS: It was a prospective case series spanning over 6 years. Patient enrolment started from January 2009 and data collection completed in January 2015. Patient with BMI (weight in kilogram/height in meter square) of more than 35 were included in the study. Follow up was at 2 weeks, 1 month, 6 months and 12 months. Success was defined as 25% of excess weight loss at 1 year. Paired t-test was used as a test of significance. RESULTS: A total of 34 patients were included in the study over a 6-year period, 3 were lost to follow up and one patient died of cardiac arrest. Data of 30 patients is considered for final analysis. Mean age was 39.5±10 years, while mean BMI 45.8±6.3 (range 37.1-62.2). Average weight of the patients preoperatively was 129.9±20.8 kg while mean excess weight was 70.3±20.8 kg. Average weight loss at two weeks was 8.9±2.9 kg, at one month 14.7±4.6 kg, at 6 months 25.0±7.6 kg and at twelve months was 31.4±6.8 kg. Mean percentage of excess weight loss after 2 weeks was 13.5±4.6%, at one month 22.0±6.1%, at six months 37.6±12.0% and at twelve months 47.3±10.1%. CONCLUSIONS: Laparoscopic sleeve gastrectomy is an effective weight loss surgery with minimal complications. On average weight loss of about 30 kg at one year was achieved which equals to almost half of excess body weight.

Validation and reliability of Global Operative Assessment of Laparoscopic Skills for surgical residents and consultants.

OBJECTIVE: To institute and validate the Global Assessment of Laparoscopic Surgery score as a measure of intraoperative performance. METHODS: The observational study was conducted at the Services Hospital, Lahore, and the National Hospital and Medical Centre, Lahore, from August 1, 2013, to February 28, 2014, and comprised Residents, Senior Registrars and Consultants who were divided into 3 groups. The Junior group comprised Residents from years 1, 2 and3; the Intermediate group had year 4 Residents and Senior Registrars; and the Senior group included Consultants. All participants had their evaluation using Global Assessment of Laparoscopic Surgeryscore while performing dissection of gall bladder from the liver bed during laparoscopic cholecystectomy. SPSS 20 was used for statistical analysis. RESULTS: Of the 24 subjects in the study, 12(50%) were Residents, 6(25%) Senior Registrars and 6(25%) Consultants. The mean score for Junior group was 7.64±0.988, for Intermediate group 16.25±2.602 and for Senior group 22.83±1.169The score was highly reliable with intra-class coefficient 0.96, and internal consistency was excellent with Cronbach's Alpha 0.981. CONCLUSIONS: Global Assessment of Laparoscopic Surgery was found to be a valid and reliable measure of intraoperative laparoscopic skills.

Laparoscopic resection of gastro-intestinal stromal tumour.

Gastro-Intestinal Stromal Tumours are rare tumours, constituting less than 1% of gastrointestinal tumours. They are the most common mesenchymal origin tumours of gastro-intestinal tract. Tyrosine kinase c-kit oncogene mutation is found in all cases. These tumours are sensitive to imatinib. They are usually noted incidentally on endoscopy or present with haematemesis after ulceration. We are reporting the laparoscopic resection of GIST in a 67 year old male who had presented with haematemesis. He was found to have a gastric polyp on endoscopy. Endoscopic ultra-soundshowed the tumour to be arising from the submucosa. Histo-pathology showed the tumour to be GIST. Patient is currently undergoing chemotherapy.

Mesh fixation vs. non-fixation in total extra peritoneal mesh hernioplasty.

OBJECTIVE: To compare mesh fixation with non-fixation and its effect on outcome. METHODS: The interventional prospective study was conducted at the National Hospital & Medical Centre, Lahore from January 2007 to December 2008. After the two-year intervention period, the patients were followed up for 5 years. The selected patients were divided into two groups. In group 1, mesh fixation was performed with metal non-absorbable tackers and in group II no fixation of mesh was performed. Patients were followed up at 6, 12, 24 and 60 months. RESULTS: Of the 63 patients in the study, 32(50.7%) were in group I and 31(49.2% in group II. The Mean pain score in group I was 4.7±0.683 and 4.1±0.860 in group II (p< 0.001). Urinary retention was more common in group 1 (p>0.05), while recurrence was more common in group II (p>0.05). CONCLUSIONS: Pain was significantly less in the non-fixation group, while urinary retention and recurrence were not significantly increased. Non-fixation is a viable option for total extraperitoneal mesh hernioplasty and should be preferred over mesh fixation.

Pre-operative antibiotic use reduces surgical site infection.

OBJECTIVE: To assess the efficacy of World Health Organisation Surgical Safety Checklist as a simple, reliable and effective tool to ensure appropriate administration of intravenous antibiotics. METHODS: The prospective interventional study was conducted in three phases at Mayo Hospital, Lahore, from May 2011 to January 2012. The first phase comprised baseline data collection, followed by implementation of World Health Organisation Surgical Safety Checklist, and finally post-implementation data collection. The duration of each phase was 3 months. Primary end points were discharge from hospital, 30 days or death of the patient. RESULTS: Of the 613 patients in the study, 303(49.4%) were in the pre-implementation phase and 310(50.5%) in post-implementation phase. Adherence of optimal administration of antibiotic increased from 114(37.6%) to 282(91%) (p<0.001). The rate of post-operative infection fell from 99(32.7%) to 47(15.2%) (p<0.001). Mean hospital stay was reduced from 7.8±5.7 days to 6.5±5.6 days (p<0.001). CONCLUSIONS: Appropriate and timely administration of antibiotic reduced surgical site infection by more than half. Hospital stay was shortened by 1.3 days on average which results in considerable reduction in morbidity, mortality and costs.

Laparoscopic cystgastrostomy: A Pakistani perspective.

Laparoscopic Pancreatic Pseudocyst (PP) surgery can be performed via anterior or posterior cystogastrostomy, endoscopy-assisted surgery and cystojejunostomy. We conducted a prospective analysis of our patients undergoing laparoscopic cystogastrostomy to analyse the merits and demerits of the procedure. In a period of 3 years from January 2010 to December 2012 all the patients who underwent laparoscopic drainage of pancreatic pseudocysts were prospectively analysed. A total of 12 patients underwent a transgastric anterior cystogastrostomy with a stoma size of 4.5cms. There was no intraoperative or postoperative bleeding or leakage on anastomotic lines. Post-op pain score on the first post-op day was 4 (2-5) on the Visual Analogue Scale (VAS). Average hospital stay was 4.1±2.3 days. All patients had complete resolution of symptoms on follow-up. Follow-up computed tomography (CT) scans on 8 patients showed complete resolution of the cysts. Laparoscopic cystogastrostomy is a safe and feasible method and provides efficient drainage of PP.

Modified Limberg's flap versus primary closure for treatment of pilonidal sinus disease: a comparative study.

OBJECTIVES: To compare the outcome of Rhomboid excision and Modified Limberg's flap closure with excision and primary closure for the treatment of Sacrococcygeal Pilonidal sinus. METHODS: The study was conducted at the Surgical Department of Mayo Hospital, Lahore, from 2009 to 2012. A total of 60 patients of pilonidal sinus were randomly divided into two equal groups. The patients were operated under general anaesthesia in prone position by Rhomboid excision and Modified Limberg's flap closure with a closed suction drain in group 1, and excision and primary closure over a drain in group 2. Patients were followed up for 12 months for surgical complications of the treatment. SPSS 17 was used for statistical analysis. RESULTS: In group 1 there were 27(90%) males and 3(10%) females, while group 2 had 28(93.3%) males and 2(6.7%) females. The infection rates were observed to be 2(7%) in group 1 and 8(26.6%) (p<0.038) in group 2. The recurrence rate was only 1(3.3%) in group 1 compared to 4(13.3%) in group 2. Average hospital stay was 1.63±0.67 days group 1 and 2.8±1.24 days in group 2. CONCLUSION: Modified Limberg's flap closure is an effective treatment modality for pilonidal sinus disease with 1.5 times less infection rate, 4 times less recurrence rate and 40% in-hospital time.

Acute and Complicated Inflammatory Pericarditis: A Guide to Contemporary Practice.

Inflammatory disease of the pericardium represents a relatively common presentation, especially among the young. For the most part, inflammatory pericardial disease can be expeditiously and effectively managed without significant sequelae. However, some individuals present with severe and recurrent illness, representing significant therapeutic challenges. During the past decade, there have been great strides made in developing an evidence-based approach to management of inflammatory pericardial disease, the result of which has been the development of (1) a systematic, protocoled approach to initial care; (2) targeted therapeutics; and (3) specialized, collaborative, and integrated care pathways. Herein we present a review of the current state of the art as it pertains to the diagnostic evaluation and therapeutic considerations in inflammatory pericardial disease with a focus on acute and complicated pericarditis.

Impact of SSO-ASTRO Margin Guidelines on Re-excision Rate in Breast-conserving Surgery: A Single-center Experience.

Introduction: Breast-conserving surgery (BCS) has been historically linked with a high rate of re-excision. To address this issue, the Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) developed consensus guidelines in 2014 to standardize practices and improve clinical outcomes for BCS patients. In our tertiary cancer care hospital, we assessed the impact of these guidelines on the re-excision rate following BCS. Materials and Methods: We conducted a retrospective study on breast cancer patients who underwent BCS at the Shaukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, Pakistan. The study compared the re-excision rate before the implementation of the SSO-ASTRO consensus guidelines (November 2015-July 2017) and after the implementation (January 2018-August 2019). Margins were considered positive if "ink on tumor" was present and negative if "no ink on tumor" was present. Fisher's exact test or Chi-square test was used to compare the re-excision rates between the pre- and post-guideline periods. Results: A total of 919 patients were identified, with 533 from the pre-guideline period and 386 from the post-guideline period. Of the 919 patients, 31 with ductal carcinoma in situ (DCIS) were excluded from the re-excision analysis because the guidelines were not implemented on the DCIS. Furthermore, the overall rate of re-excision in our data was 4.3%. The re-excision rate decreased from 71.1% to 28.9% (P ≤ 0.05) following the adoption of the guidelines. We observed a statistically significant decrease in the re-excision rate after implementing the SSO-ASTRO guidelines. Conclusion: Implementation of the SSO-ASTRO margin guidelines led to a notable decrease in the overall re-excision rate in our data set. These findings suggest that continued adherence to the guidelines may lead to a further reduction in the re-excision rate in the future.