Pre-stenting in a difficult ureter: what is the incidence?

Objective: To estimate the occurrence of [difficult ureter] where stenting was performed as a preliminary step for passive ureteric dilatation before second ureterorenoscopy and to create awareness of the incidence of this abnormality in our setting

Study Design: Cross sectional prospective case review study

Place and Duration of Study: Study was conducted in Urology department of PNS Shifa Karachi, from Jul 2017 to Mar 2018

Material and Methods: All patients who presented to our institute for ureteric calculi with normal creatinine and no urosepsis were included in the study. The procedure was carried out either in spinal anesthesia or general anesthesia using laryngeal mask. The outcome data of ureterorenoscopyin all patients including those patients who required pre-stenting for difficult ureters were documented

Results: Ureterorenoscopy was performed in 164 patients [mean age 34 years, range 14 to 70 years] for treatment of ureteric calculi. Among these 29 patients [17.7 Percent] had upper, 52 patients [31.7 Percent] had middle and 83 patients [51 Percent] had lower ureteric calculi. Stone clearance was achieved in 135 [82 Percent] of patients. In 16 [9.7 Percent] patients the stone had to be pushed back for Extracorporeal Shock Wave Lithotripsy later. [Difficult ureters] were encountered in 13 patients [7.9 Percent] in which Double J stents were placed under fluoroscopy and staged successful ureterorenoscopy were performed after 2 to 3 weeks without any complication

Conclusion: There was a 7.9 Percent [about 8 Percent] incidence of encountering [difficult ureter] while performing ureterorenoscopy for ureteric calculi resulting in failed access for which a Double-J stent will have to be introduced to avoid ureteric injury. This possibility of occurrence of a [difficult ureter] and a staged ureterorenoscopy after 2 to 3 weeks should be discussed with the patients preoperatively, in order to avoid patient dissatisfaction after the procedure and allay his undue emotional suffering

Vascular resection and reconstruction in pancreatic tumours

Option for borderline resectable pancreatic cancer is pancreaticoduodenectomy [PD] with vascular resection and reconstruction. We would like to share our experience of vascular reconstruction. First patient was a 51-year male with pancreatic head carcinoma, involving posterior wall of portal vein [PV] and replacing right hepatic artery [RHA]. Along with PD, he underwent PV and RHA resection and reconstruction. Second case was a 33-year female who had distal pancreatic cyst and PV-splenic vein junction involved by tumor. Distal pancreatectomy+splenectomy and PV primary resection-reconstruction was done. Third case was a 72-year male with pancreatic neck adenocarcinoma involving PV-SMV junction. Subtotal pancreatecomy+splenectomy was done along with PV-reconstruction via splenic vein patch graft. Fourth case was a 77-year male with cystic pancreatic head mass involving PV. PD with resection and reconstruction of portal vein was done. Fifth case was a 35-year female with peri-ampullary tumor replacing RHA, coursing through the pancreatic parenchyma. So RHA was resected and reconstructed in an end-to-end fashion. Vascular resection-reconstruction can be done in borderline pancreatic cancer patients, and a considerable survival benefit can be achieved

Surgical management for symptomatic giant liver hemangiomas: a meta-analysis

Objective: To conduct a meta-analysis of reported evidence on surgical management for symptomatic giant liver hemangiomas

Methodology: A systematic literature search was conducted to identify studies on adult patient surgeries for symptomatic giant liver hemangiomas from January 2009 to July 2015. The primary outcome measures included postoperative symptom resolution, mortality, complications, and blood transfusions. Quality of life after surgery was taken as a secondary outcome. Meta-analysis was performed using a random-effect model with comprehensive meta-analysis software

Results: Fourteen studies with 1,557 patients were included. There were only two mortalities. Overall event rate for minor and major complications was low as 0.15 and 0.14, respectively, with a high symptom resolution rate of 0.69 [95%, CI 0.64-0.73]. Pooled analysis for blood transfusion stayed insignificant due to high calculated heterogeneity across studies. Quality of life results after surgery are reported good by three studies, in most of their patients. The adverse outcome rate between enucleation and resection was comparable

Conclusion: Liver hemangioma surgery is a safe treatment option with negligible mortality and low morbidity. It is effective in terms of symptom control and overall quality of life

Surgical outcome of pancreaticoduodenectomy in pancreatic and periampullary neoplasms

Objective: To report the results in the surgical treatment of pancreatic and periampullary neoplasms with emphasis on surgical technique, short-term postoperative outcome and the lessons learnt

Study Design: Case series

Place and Duration of Study: This study was carried out at Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, from October 2014 to May 2016

Methodology: Patients undergoing surgical treatment of pancreatic and periampullary neoplasms were selected. Patients' characteristics including demographics, surgical technique, and 30-day morbidity and mortality were recorded. International Study Group of Pancreatic Fistula [ISGPF] classification was used to define postoperative pancreatic fistula and Clavien-Dindo classification to grade complications

Results: A total number of 65 patients underwent the trial of dissection; 50 had pancreaticoduodenectomy and 15 patients underwent palliative bypass and were excluded from analysis. Sixty-four percent were males and 36% were females. The most common tumor was periampullary [n=29, 58%] followed by pancreatic head [14, 28%] and duodenal tumors [n=07, 14%]. Mean age was 52.92 +/- 13.27 years; mean operating time was 470 +/- 358.28 minutes and median blood loss was 400 [287-500] ml. Pancreaticogastrostomy [PG] was the preferred reconstruction technique in 37 [74%] verses pancreaticojejunostomy [PJ] in 13 [26%] patients. Four [08%] patients needed portal vein reconstruction and two [04%] replaced right hepatic artery resection and reconstruction due to tumor involvement. There were seven Grade A, and one Grade B and C pancreatic fistulae each. Three patients [06%] needed endoscopic therapy for gastrointestinal hemorrhage from pancreatic stump. There was one death in postoperative period

Conclusion: Pancreaticoduodenectomy is a safe procedure with excellent postoperative outcome, if carried out in a specialized hepato-pancreato-biliary unit. A PG reconstruction can be a safer alternative to PJ

Impact of different treatment modalities on the outcome of pancreatic cancer

Objective: To analyze overall survival patterns of our pancreatic cancer patient population managed with a curative or palliative intent

Study Design: Analytical study

Place and Duration of Study: Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, from January 2000 till February 2015

Methodology: A retrospective review of the data of all of our pancreatic cancer patients was performed, using the hospital information system. Patients with tumor other than adenocarcinoma or a histopathologic diagnosis not made at our hospital are excluded from the study, along with patients having an incomplete medical record for all included variables. The main outcome measure was overall survival in months from the date of diagnosis. All results were segregated and analyzed according to the intervention modality used, i.e. group A: surgery with curative intent, group B: Palliative chemotherapy, and group C: Supportive care. Results were controlled for the confounding variables including age, gender, significant comorbid conditions, stage of disease at initial presentation, tumor location, and histological grade

Results: Among the 197 patients fulfilling the inclusion criteria, 21 [10.7%] were excluded as they were lost to follow-up. Overall Kaplan-Meier survival analysis gave a 56% one-year survival, 22% at 3- and 16% at 5-year. The subset analysis on Cox-regression survival plot showed inferior survival with advancing stage of the disease and a treatment less than definitive surgical resection and adjuvant chemotherapy. On Cox-proportional regression analysis, stage of the disease and treatment modality were only independent predictive factors for overall survival [p < 0.01]

Conclusion: Stage for stage, surgery with curative intent [group A] or palliative chemotherapy [group B] showed a trend towards improved survival as compared to supportive management [group C] alone. The results were more significant for surgical resection arm

Antimicrobial susceptibility pattern of acinetobacter baumannii and rate of carbapenem resistance at atertiary care hospital in Karachi

Objective:To know frequency of carbapenem resistance in Acinetobacter baumannii and its antimicrobial susceptibility pattern at PNS Shifa Hospital Karachi

Methodology:This study was carried out at PNS Shifa Hospital, Karachi, from 1st January 2015 till 31st October 2016. Samples from patients having different sites of infection were received in the laboratory from different wards of hospital and inoculated on culture plates. After 24 hours incubation, identification of non-lactose fermenter colonies of Acinetobacter baumannii was done by conventional methods. Antimicrobial susceptibility was recorded for Beta-lactam group of antimicrobials, Beta-lactam/Beta-lactamase inhibitor combination group, tetracyclines, fluoroquinolones and aminoglycosides as per CLSI guidelines

Results: During the study period, a total of 117 Acinetobacter baumannii isolates were identified from culture of different samples representing 5.0% of all bacterial isolates [n=2352] and 7.5% of all Gram-negative bacilli [n=1559] throughout the hospital. Out of one hundred and seventeen isolates, 52.1% [n=62] were found carbapenem resistant.Higher percentages of Acinetobacter baumannii were isolated among samples received from medical wards [26.4%].Percentage of Acinetobacter baumannii isolated was highest from the blood culture specimens [22.2%]. Isolates showed higher resistance against ceftriaxone [84.6%] followed by cotrimoxazole [65.8%] and ciprofloxacin [63.2%].Comparatively low resistance against doxycycline and minocycline [23.9%], and tigecycline [38.9%] was observed.Resistance pattern to other antimicrobials was gentamycin [54.7%], amikacin [55.6%], piperacillin-tazobactam [48.7%], cefoperazone-sulbactam [51.35%], meropenem [52.1%] and imipenem [52.1%]

Conclusion: Carbapenem resistance in Acinetobacter baumannii is increasing and therapeutic options left to treat are highly toxic especially for patients with co-morbidities

Pattern of dermatophytes among dermatological specimens at AFIP, Rawalpindi

To determine the types and prevalence of dermatophytes from the clinical specimens received at Armed Forces Institute of Pathology [AFIP]. Study design is descriptive. The study was carried out at the Department of Microbiology, AFIP Rawalpindi from June 2009 to May 2010. Total of 400 different clinical specimens were dealt during the study period. After direct microscopy, they were inoculated on Sabouraud's dextrose agar with and without antimicrobials. The plates were incubated at 220C and examined twice weekly up to four weeks for any fungal growth. Species identification was done through colony morphology and microscopic examination of lactophenol blue preparation. Out of total specimens, 221[55.25%] yielded fungal growth. The overall yield of dermatophytes from different specimens was in the order of nail [78%], followed by skin [18.3%] and hair [3.3%]. Mycological infections have growing importance because of the increasing population of immune-compromised patients warranting a high index of suspicion

Efficacy of zinc as an antibacterial agent against enteric bacterial pathogens

Background: Diarrhoea is a serious threat all over the world with great economic implications especially evident in the developing world. This study was aimed at determining in vitro efficacy of Zinc [Zn] against common enteric bacterial pathogens. Method: A total of 100 bacterial enteric pathogens: Salmonellae [n=16], enteropathogenic Escherichia coli [EPEC] [n=26], Shigellae [n=28] and Vibrio cholerae [n=30] were isolated from diarrhoeal stool specimens at Department of Microbiology, Armed Forces Institute of Pathology Rawalpindi during Aapril 2009 to Jan 2010. These isolates were tested against various concentrations of Zn supplemented in Mueller Hinton [MH] agar using a multipoint inoculator. A minimum inhibitory concentration of active Zn in ZnSO4.7H2O ranging from 0.03 mg/ml to 1 mg/ml was used. Results: Zn completely inhibited the growth of all the tested pathogens and most of them were inhibited at a concentration of 0.06 mg/ml to 0.5 mg/ml of Zn. Conclusions: Zinc has an excellent antibacterial activity against enteric bacterial pathogens common in our setup which may provide basis for treatment of diarrhoea. Clinical study based on these findings is recommended. Keywords: Diarrhoea, zinc, antibacterial, Enteric Pathogens, Cholera, Salmonella, E. coli, Shigella

Non-dermatophyte moulds as pathogens of onychomycosis

To determine the role and pattern of non-dermatophyte moulds as causative agents of onychomycosis. Case series. Department of Microbiology, Armed Forces Institute of Pathology [AFIP], Rawalpindi, from November 2009 to July 2010. Nail clippings and nail scrapings were obtained from abnormal looking nails with treatment and detection failure for onychomycosis. Microscopic [40% potassium hydroxide mounts] examination and culture on Sabouraud's dextrose agar [SDA], SDA containing chloramphenicol, and SDA containing actidione and chloramphenicol were used for species identification. Non-dermatophyte moulds were isolated from 32 out of the total 47 culture positive cases [68%]. Alternaria alternata was the commonest species [46%]. Dermatophytes were isolated from only 7 patients [15%] belonging to genus Trichophyton. Yeasts were isolated in 8 [17%]. There was no fungal growth in 53% of cases. The non-dermatophytes should be considered important in evaluating the culture negative cases for dermatophytes as well as those cases ending up in treatment failure after empirical treatment for dermatophyte infections

Extended-spectrum beta-lactamase production in sbigella flexneri

Emergence of multidrug-resistant strains of Shigella is a growing concern across the globe. Third-generation cephalosporins are used for treating infections caused by multidrug-resistant Shigellae. However, resistance to these cephalosporin antibiotics due to extended-spectrum beta-lactamases, has emerged as a new problem. So far extended-spectrum beta-lactamases producing Shigella has not been reported from Pakistan. We report such a case in Shigella flexneri from an 8-year old girl with acute dysentery

Abdominal wound closure: a prospective randomized trial of polypropylene and polydioxanone

Results of a prospective study on 164 patients, comparing the polydioxanone [PDS[R]] and polypropylene [Prolene [R]] in laparotomy wound closure; over a 30 month period are presented. All types of laparotomy wounds were considered for evaluation. Patients were analyzed for early and late wound related complications. Overall wound infection was 11%. Whereas no significant difference between two sutures was noticed for the early postoperative complications, persistent wound pain, palpable knots, and suture sinuses were significantly less with less with PDS in continued follow up [mean 24.5 months]. With the comparable safety in early postoperative period and significantly lower incidence of delayed complications, PDS can be regarded as near-to-ideal suture material for closing all types of laparotomy wounds

Role of sclerotherapy as primary treatment of hydrocele

A variety of surgical procedures are available to treat hydrocele. Aspiration alone and aspiration followed by sclerotherapy has also been used to treat primary hydrocele. An original study is presented, which was carried out with a view to assess the outcome of sclerotherapy as primary treatment of hydrocele, its related complications, cost-effectiveness and comparison of results with surgical treatment of hydrocele. Design: It is a prospective study. Place and Duration of Study: The study was conducted at the Department of Surgery, Mayo Hospital, Lahore from January 1999 to December 2000. Subjects and A total of fifty patients were included in the study having primary hdroceles, twenty-five for each procedure i.e. sclerotherapy and surgery. A careful history was taken and detail clinical examination of all the patients performed. Sclerotherapy with STD after aspiration of hydrocele fluid was carried out in twenty-five patients and the remaining patients treated surgically with Jaboulay's procedure. The study proved that sclerotherapy of hydrocele is a safe mode of treatment. It is quick, effective and causes less morbidity as compared to surgical treatment of hydrocele. Any form of anesthesia is not required for this procedure and patient's satisfaction is reasonable. It is less expensive as compared to surgery and may be used as primary treatment of the hydrocele. Sclerotherapy is the treatment of choice for primary hydrocele. Complications like pain, hematoma and infection are less than surgical procedure. Hospital stay is minimal and does not effect day-to-day work of the patient having sclerotherapy. Cost of treatment is significantly less than surgery. Post treatment recovery and patient's satisfaction is excellent in sclerotherapy as compared to surgical treatment