Effect of formalin fixation on surgical margins in breast cancer surgical specimen.

Margin analysis in breast surgery is an important predictor of local recurrence and can have vital impact on the postoperative treatment planning. Objective. The aim was to assess the mean reduction in the closest tumor-free surgical margin in millimeters of breast cancer specimens following formalin fixation. Materials and Methods. We conducted a cross-sectional study at the Aga Khan University Hospital from March 30, 2010 to January 20, 2011. One hundred consecutive breast tumour surgical specimens which had macroscopically visible tumour were included. The cancer type included both in situ and invasive cancers. Excluded were the patients who had previous surgery or systemic/radiation therapy. The closest tumor-free margin was recorded and compared with the margin after formalin fixation. P value of <0.05 was considered significant. Results. The mean age of our 100 patients was 53 years with the majority of the patients having undergone mastectomy for predominantly invasive ductal carcinoma. Following formalin fixation, the mean reduction of the closest tumor-free margin was noted as 2.14 mm which was found statistically significant. Conclusion. Considerable shrinkage of tumor-free surgical margins of breast cancer specimen was noted after formalin fixation. This inference can have implications on the postoperative management plan.

Factors affecting anastomotic leak after colorectal anastomosis in patients without protective stoma in tertiary care hospital.

OBJECTIVE: To determine the factors associated with clinically significant anastomotic leak in patients having undergone large intestinal anastomosis. METHOD: The retrospective study at the Aga Khan University Hospital, Karachi, comprised data between January 2000 and March 2010, related to patients who underwent colorectal anastomosis. Demographic details of the patients, as well as preop, intraop and postop risk factors were recorded. Anastomotic leak was identified as per the defined criteria. Outcome of patients was recorded as postop hospital stay and mortality. Univariate and Multivariate analyses were applied to identify risk factors for anastomotic leakage. RESULTS: Among the total 127 patients in the study, anastomotic leak occurred in 19 (15%) patients (Group 1), while there was no clinical leak in 108 (85%) patients (Group 2). Univariate analysis showed 8 factors to be affecting the anastomotic leak: operation time (p = 0.003), intraoperative blood loss (p = 0.006), intraoperative blood transfusion (p = 0.013), indication of surgery malignancy vs. benign (p = 0.049), type of surgery elective vs. emergency (p = 0.037), intraop use of vasopressor (p = 0.019), segment of bowel anastomosed left side vs. right side (p = 0.012), and drain placement vs. no drain placed (p = 0.035). Preop immunosuppressive therapy was borderline significant (p = 0.089). Multivariate analysis showed that left vs. right sided anastomosis (p = 0.068), blood transfusion > 2 pack cells (p = 0.028), smoker vs. non-smoker (p = 0.049), elective vs. emergency surgery (p = 0.012) were the independent risk factors which significantly affected the outcome of bowel anastomosis. Mortality rate was 15.79% (n = 3/19) in Group 1, while it was 1.85% (n = 2/108) in Group 2 (p = 0.02).The postop hospital stay was 15 +/- 5.44 days in Group 1, while it was 7.51 +/- 4.04 days in Group 2 (p > 0.001). CONCLUSION: In colorectal anastomotic surgeries temporary diversion stoma formation needs to be considered on the basis of risk factors to decrease mortality and morbidity associated with anastomotic leak.

Repair of large and giant incisional hernia with onlay mesh: perspective of a tertiary care hospital of a developing country.

PURPOSE: Ventral incisional hernias, especially large and giant, carry significant post repair complications. This retrospective review is undertaken to determine the outcomes of large and giant incisional hernia repair as well as the risk factors of recurrence and surgical site infection at a tertiary care hospital in developing country. METHOD: This case series included adult patients, operated between January 2001 and June 2009 for incisional hernia of size ≥ 10 cm (vertical or horizontal dimension) at our institute with follow up of at least one year. The charts of selected patients were reviewed by a general surgery fellow for hernia recurrence, complications, mortality and the predictive factors. RESULTS: Sixty out of 391 patients operated for incisional hernia were found eligible; of them 29 (48.3%) had large (defect of 10-15 cm) and 31 (51.7%) had giant hernia (defect size >15 cm). Mean age of patients was 43.8 ± 11.8 with female preponderance (male: female; 1:1.6). Fourteen (23.33%) patients developed complications and there was no mortality. Surgical Site Infection (SSI) was observed in 13 (21.67%) patients and significant predisposing factors for SSI (with or without mesh infection) were diabetes mellitus, emergency surgery, contaminated surgery and recurrent incisional hernia. With a mean follow up of 20.05 ± 8.8 months (range: 12-48 months), four (6.67%) patients had recurrence of hernia. CONCLUSIONS: Repair of large and giant incisional hernia using prosthetic non-absorbable mesh, mainly onlay, carry acceptable rates of complications.

Emergency incisional hernia repair: a difficult problem waiting for a solution.

BACKGROUND: Emergency repair of incarcerated incisional hernia with associated bowel obstruction in potentially or contaminated field is technically challenging due to edematous, inflamed and friable tissues with occasional need for concurrent bowel resection and carries high rates of post-operative infectious complications. The aim of this study was to retrospectively assess the wound related morbidity of use of permanent prosthetic mesh in emergency repair of incarcerated incisional hernia with associated bowel obstruction. We also describe a new technique of leaving the mesh exposed to heal by secondary intention with granulation tissue. METHODS: Between 2000 and 2010 a total of 60 patients underwent emergency surgery for incarcerated incisional hernia with associated bowel obstruction with placement of permanent prosthetic mesh. The wound was closed after hernia repair in 55 patients while it was left open to granulate in 5 patients. RESULTS: In the group of patients with primary wound closure, 11 patients developed superficial surgical site infection, 5 developed deep wound infection and one patient had cellulitis. These patients were treated with wound debridement and antibiotics. Mesh removal was required in one patient. There were no infections in the group of patients who had their surgical wounds left open. One patient in this group died on the fifth postoperative day from septicemia. CONCLUSION: Use of permanent prosthetic mesh in emergency repair of incarcerated incisional hernia with associated bowel obstruction. in contaminated field is associated with high risk of wound infection.

Predicting recurrence and progression in non-muscle-invasive bladder cancer using European organization of research and treatment of cancer risk tables.

INTRODUCTION: We determined the recurrence and progression at 1 year in patients with non-muscle-invasive urothelial carcinoma who underwent transurethral resection of bladder tumor (TURBT) and compared those with the calculated risk according to the European Organization of Research and Treatment of Cancer (EORTC). MATERIALS AND METHODS: Follow-up data of 92 patients with non-muscle-invasive bladder cancer who underwent TURBT were reviewed, and their 1st year recurrence and progression were recorded. The risk of recurrence and progression were calculated for 1 year according to the EORTC scoring system, using tumors' stage, grade, size, and multiplicity, and the presence of carcinoma in situ and previous recurrence episodes. The outcomes were compared with the EORTC's predictive scores. RESULTS: The patients were 75 men and 17 women with an age range of 31 to 91 years. Sixteen patients (17.4%) had a recurrent disease, 41 (44.6%) had a tumor larger than 3 cm in diameter, 35 (38.0%) had multiple lesions, 2 (2.2%) had carcinoma in situ, 73 (79.3%) had stage T1 lesions, and 8 (8.7%) had a high-grade disease. Recurrence was found in 34 patients (37.0%). The recurrence rates were 20.0%, 28.2%, 40.5%, and 83.3% in groups with the predicted EORTC risks of 15%, 24%, 38%, and 61%, respectively. There were 2 patients (2.2%) with progression of the diseases. CONCLUSION: A significant concordance was noted between the EORTC's calculated risk and the recurrence rate of stage Ta T1 bladder cancer at 1 year. Progression was less than that predicted, probably due to our small sample size.

A unique variant of intestinal tuberculosis.

Duodenum is a rare site of involvement in intestinal tuberculosis. We report a 19 years old boy who presented with nonbilious vomiting and weight loss. His workup showed stricture in ascending colon, multiple liver abscesses with pneumobilia on CT scan. Upper GI endoscopy revealed stricture in 2nd part of duodenum distally. He was operated and duodenojejunostomy with limited right hemicolectomy (for stricture in this part of gut) were done. Biopsy report was suggestive of tuberculosis. Antituberculous treatment was started. He responded well and gained 20 kg weight at 3 months follow-up.