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.

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.

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.

Karachi Cancer Registry (KCR): Age-Standardized Incidence Rate by Age-Group and Gender in a Mega City of Pakistan.

OBJECTIVES: To estimate the cancer incidence by age group and gender for the population of Karachi Division by analyzing the Karachi Cancer Registry data of 2017-19. SETTINGS: The population of Karachi division is 16.1 million according to national census 2017. 'Karachi Cancer Registry' which is a part of 'National Cancer Registry' is collecting data from eight major hospitals in Karachi since 2017. For outcome measures, cancer counts and the age standardized incidence rates (ASIR) per 100,000 population were computed for age groups (0-14, 15-19 and ≥20 years), in both genders and all cancer site/type. METHODS: The population denominators were based on the population of Karachi division estimated at 16.1 million in the population census, 2017. Counts and age-standardized incidence rates (ASIR) were calculated for each of the three age categories. RESULTS: From Jan 2017 till Dec 2019 a total of 33,309 malignant cases were recorded in KCR database comprising 17,490 (52.5%) females and 15,819 (47.5%) males. ASIRs in age groups 0-14, 15-19 and ≥ 20 years, among female were 11.5, 2.4 and 223.6 and in males were 17.6, 3.2 and 216.7 respectively. The commonest diagnosis in children, adolescent and adults were (1) among females: children; bone (3.12),  leukemia (2.09) brain/CNS (1.26); in adolescents: bone (0.78), brain/CNS (0.27), connective and soft tissue (0.11), in adults: breast cancer (76.07), oral cancer (16.68) and ovary (10.89) respectively, and (2) among males: children; bone (4.56),  leukemia (2.79) and brain/CNS (1.88); in adolescent; bone (1.19), brain/CNS (0.31) and leukemia (0.21) and in adults: oral cancer (42.83), liver (16.10) and bone (13.37) respectively. CONCLUSION: Oral Cancer, a largely preventable cancer is the leading cancer in Karachi adult males while in female adults Breast Cancer is the leading cancer followed by Oral Cancer. In children and adolescents Bone, Leukemia and Brain/CNS malignancies are most common.
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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.

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.

Benign esophageal strictures: behaviour, pattern and response to dilatation.

OBJECTIVE: To evaluate the endoscopic dilatation of benign esophageal strictures and its outcome. METHODS: A prospective descriptive study was conducted at Surgical Unit 4 of Civil Hospital Karachi, over a period of 24 months, from August 2006 to July 2008. Twenty seven patients with benign esophageal strictures underwent esophageal dilatation under fluoroscopic guidance using Savary Gilliard Dilators and guide wire. Follow up was done weekly for 2 weeks and monthly for a minimum of 6 months. Treatment success was gauged according to improvement of dysphagia. RESULTS: A total of 27 patients were included in the study. There were 16 (59.3%) corrosive strictures, 10 (37%) were peptic strictures and one (3.7%) was due to extrinsic compression. Majority of the corrosive strictures, 11 (68.75%) were suicidal in intent p < 0.001. Mean dilatation frequency for strictures longer than 5cms was 7.10 +/- 5.322 vs. 3.47 +/- 3.281 for strictures < 6cms (p < 0.037). Corrosive strictures were seen more commonly in the upper esophagus as compared to peptic (Mean 22.44 +/- 5.240 cm vs. 30.20 +/- 4.780 cm), p < 0.001. Only 81.4% corrosive stricture could be adequately dilated at initial dilatation as compared to 100% in peptic strictures. Mean symptomatic recurrences per month were 0.6919 +/- 0.300 in corrosives and 0.365 +/- 0.293 in peptic strictures (p < 0.003). There were 4 procedure related perforations, all in patients with corrosive strictures. Overall mortality was 7.4%. CONCLUSION: Endoscopic dilatation is safe and effective in treating benign and corrosive esophageal strictures, which have a higher complication rate. Mean recurrence rate decreased over a period of time in both peptic and corrosive strictures.

Palliative management of irresectable carcinoma esophagus using self expandable metallic stent (SEMS).

OBJECTIVE: To evaluate the symptomatic relief of dysphagia after stenting in patients with carcinoma esophagus METHODS: A prospective non randomized descriptive study was conducted at Surgical Unit 4, Civil Hospital Karachi, Pakistan over a period of 1 year, from August 2006 to July 2007. A total of 41 patients with biopsy proven carcinoma esophagus having irresectable disease on the basis of CT scan or poor risk for major surgery were included in the study. Self expandable metallic stents were placed under fluoroscopic guidance in all the patients. Follow up was done weekly for 1 month and monthly for 6 months or till death of the patient. Data was analyzed using SPSS version 11. RESULTS: Age of the study population ranged from 25-80 years with mean age of 51.49 +/- 14.25 years. Male to female ratio was 1.15:1. Preoperative dysphagia for solids was seen in 4.9%, for semi solids in 31.7%, and for liquids in 63.4%. 80.5% of patients had squamous cell carcinoma and 19.5% of patients had adenocarcinoma. Dilatation prior to stenting was done up to 12.8 mm in 65.9%. Complete relief of dysphagia was seen in 73%. No procedure related mortality was seen in our study. Overall complication rate was 29.2%. CONCLUSION: SEMS is an effective method for the relief of dysphagia in patients with irresectable carcinoma esophagus.

Colonic lipoma.

Lipoma of the colon is rare and may lead to intestinal obstruction. We have presented two cases of colonic lipoma. Both were elderly females, one presented with diarrhea and the other with sub-acute intestinal obstruction. After colonoscopy surgical removal was done. Histopathology revealed lipoma