[Cerebral atypical rhabdoid/teratoid tumor: report of two cases]

The cerebral atypical rhabdoid/teratoid tumor constitutes one of the most aggressive tumors of children. Such tumors are equally characterized by a critically and speedly mortal development. The optimal management of such tumors remains unknown. The authors report two cases of cerebral atypical rhabdoid teratoid tumor in 8- and 10-year girls and discuss the histological features, immunochemistry study, prognosis and treatment of these rare tumors.

Audit of splenectomy at Jinnah Postgraduate Medical Centre, Karachi

OBJECTIVE

Splenectomy is often performed in patients with heamatalogical diseases or trauma who are at high risk of complications. Our aim is to perform an audit on splenectomy in order to determine the reasons for the operation, its complication and compliance with the recent recommendations for post-splenectomy patients at Jinnah Postgraduate Medical Centre.

DESIGN

It is a Descriptive study conducted in surgical ward 2 at Jinnah Postgraduate Medical Centre from June 2003 to June 2008.

METHODS

A retrospective review of hospital records of surgical ward 2 of consecutive splenectomy patients with a mean follow up of 12 months.

RESULTS

Fifty-five patients underwent splenectomy in 6 years duration. The mean age was 26.7 years. The indication for splenectomy was mainly heamatological diseases and trauma. Vaccination was done in 83.6% patients. Twelve patients had postsplenectomy complications, although there were no cases of OPSI. Mean hospital stay was 6.4 days.

CONCLUSION

We still lack compliance with the standard guidelines for post-splenectomy patients. There is space for an improvement of the vaccination rate and prophylactic antibiotic. Patients should be counselled for the risk of OPSI and should have a splenectomised card for prompt treatment. There is need for careful documentation of this important health risk and counselling of patients in the discharge summaries.

Is nasogastric decompression necessary in elective enteric anastomosis?

BACKGROUND

Placement of nasogastric tube is common surgical practice after bowel anastomosis. What is to be achieved by this prophylaxis is gastric decompression, a decreased likelihood of nausea and vomiting, decreased distension, less chance of pulmonary aspiration and pneumonia, less risk of wound separation and infection, less chance of fascial dehiscence and hernia, earlier return of bowel function and earlier discharge from hospital. We conducted a prospective observational study in Surgical Ward 2, Jinnah Postgraduate Medical Centre, Karachi from January 2008 to December 2009 to assess whether routine use of nasogastric decompression in elective enteric anastomosis can be safely omitted.

METHOD

Patients who underwent elective enteric anastomosis were included in this study. These patients were managed prospectively without nasogastric decompression. Outcome were measured in terms of time of passing flatus, nausea, vomiting, abdominal distension, pulmonary complications, wound infection, wound dehiscence, anastomotic leak, length of hospital stay and mortality.

RESULTS

Except for incidence of minor symptoms like nausea or vomiting, omission of NG tube did not lead to any serious complication like anastomotic leak, pulmonary complications wound dehiscence or death.

CONCLUSION

Nasogastric decompression can safely be omitted from a routine part of postoperative care after elective enteric anastomosis.

Short term clinical outcome of stapled haemorrhoidectomy

OBJECTIVE

To evaluate short term clinical outcome after stapled haemorrhoidectomy.

METHODS

From May 2005 to Oct 2007, 55 patients with symptomatic late 2nd and 3rd degree haemorrhoids were admitted to Surgical Ward 2, Jinnah Postgraduate Medical Centre. All of them underwent stapled haemorrhoidectomy after routine preoperative preparation. Postoperatively, pain scores, complications, hospital stay, return to routine activities, and patient satisfaction was recorded on a structured proforma. Follow-up was done weekly for 4weeks then at 2nd, 3rd and 6th month.

RESULTS

In 55 consecutive patients stapled haemorrhoidectomy was done with an operative time range of 21-30 minutes, average hospital stay was 2 days and return to daily routine activities was within one week in majority of the patients. All patients were followed at the outpatient clinic for six months postoperatively. No deterioration of symptoms occurred during the follow up. Recurrence or procedure related adverse affects, in particular impaired continence or persistent anal pain were absent.

CONCLUSION

Despite the cost and difficult access, stapled haemorrhoidectomy results in less postoperative pain, fast recovery and patient satisfaction.

Swiss roll operation for giant fibroadenoma

BACKGROUND

Fibroadenoma 5 cm or more is called giant fibroadenoma. Giant fibroadenoma can distort the shape of breast and causes asymmetry, so it should be excised. There are several techniques for excision of giant fibroadenoma. In our technique we remove them through cosmetically acceptable circumareolar incision to maintain the shape and symmetry of breast. The objectives were to assess the cosmetic results of Swiss roll operation for giant fibroadenoma. The study was conducted for six years from January, 2002 to December, 2007.

METHODS

Seventy patients of giant fibroadenoma were included in this study. They were diagnosed on history and clinical examination supported by ultrasound and postoperative histopathological examination. Data were collected from outpatient department and operation theatre. Swiss roll operation was performed under general anaesthesia.

RESULTS

Mean tumor size was 6.38 cm. Three cm and 4 cm incisions were used for tumour < or = 6 cm and > 6 cm in size respectively. Skin closed with Vicryl 3/0 subcuticular stitches. Sixteen out of 70 patients had no scar while others hadminimal scar. All patients had normal shape and symmetry of breast. On histopathology fibroadenoma was confirmed.

CONCLUSION

Giant fibroadenoma should be removed through cosmetically acceptable cicumareolar incision especially in unmarried young females who have small breast. Swiss-roll operation is superior in maintaining the shape and symmetry of breast. No major complication was found in our series except seroma formation in 10 patients.

Achalasia in a gastroenterology unit of Karachi

OBJECTIVE

To study the presentation of Achalasia and compare the response of pneumatic dilatation with surgery.

METHODS

Retrospective analysis of patient's records (January 2000-December 2005) from outpatients department of Pakistan Medical Research Council), Jinnah Postgraduate Medical Centre, Karachi was done. All patients with Achalasia were analyzed. As a protocol endoscopy, esophageal manometry, esophageal transit time and barium swallow was done to establish the diagnosis. Surgery and endoscopic guided pneumatic dilatation were offered to these patients as treatment options. Patients undergoing surgery or pneumatic dilatation were later followed to assess the efficacy and those not responding to second dilatation were also operated and follow up of all these cases were noted.

RESULTS

Forty-six patients (24 males, 22 females) with a mean age of 39.8 +/- 15.9 years were analyzed. Dysphagia was the primary symptom in thirty eight patients (83%) followed by vomiting and epigastric pain. Pneumatic dilatation was performed in 32 out of forty-six patients. Out of these cases 22 (69%) had single, and 10 (31%) had two dilatations. Two patients (6%) had perforation, one required emergency surgery, another patient was managed conservatively and recovery was unremarkable. Six patients (19%) later required surgery. Fourteen cases opted for surgery as a primary treatment. Out of 20 patients operated, four (20%) required post operative dilatation and one (5%) developed gastro-esophageal reflux.

CONCLUSIONS

Achalasia is prevalent in young age, in both sexes almost equally. Pneumatic dilatation is safe and effective, as it can be managed on outpatient basis with little morbidity and 81% success rate. Surgery is still an effective procedure with comparable 80% success rate.

[Solitary myofibroma of the mandible: a case report]

OBJECTIVES

Infantile myofibromatosis (IMF) are integrated in the group of fibromatosis juvenile-type which are benign mesenchymal lesions, characterized morphologically by a proliferation of fibroblasts and myofibroblastes, with perivascular pattern. Through a case of solitary myofibroma of the mandible, we will emphasize anatomo-clinical features and differential diagnosis.

MATERIALS AND METHODS

We report a case illustrating solitary myofibroma of the mandible in 18 month old infant.

RESULTS

The histological diagnosis was done on the identification of two separate components, a fascicular myofibroblastic pattern at the periphery with a hemangiopericytoma like pattern in the centre. Both components positive for alpha-smooth muscle actin and vimentin.

DISCUSSION

Solitary IMF is characterised by a single lesion arising from cutaneous, bony or soft tissues. Morphological and immunohistochemical examination allow the diagnosis of the typical form. The differential diagnosis includes other benign spindle cells tumours. The prognosis is excellent with possibility to regress spontaneously.

Surgical management of hyperparathyroidism

OBJECTIVE

To determine the efficacy of focused parathyroidectomy for adenoma and total parathyroidectomy with forearm autotransplantation for hyperplasia in maintaining serum calcium levels.

STUDY DESIGN

Observational case series.

PLACE AND DURATION OF STUDY

Department of General Surgery (Ward-2), Jinnah Postgraduate Medical Centre, Karachi, from January, 2002 to December, 2004.

PATIENTS AND METHODS

Sixteen patients were admitted in this time period. Eleven of these patients had primary hyperparathyroidism and 4 had secondary hyperparathyroidism due to chronic renal failure. Pre-operative localization was done with Sestamibi scan and ultrasound of neck while methylene blue was used for intra-operative localization. All patients with primary hyperparathyroidism had single gland disease and were treated with focused parathyroidectomy. In 4 patients with parathyroid hyperplasia, total parathyroidectomy with forearm autotransplantation was done.

RESULTS

In the postoperative period, 3 patients developed hypocalcemia but they were managed on oral calcium and vitamin-D supplements. All of the remaining patients became normocalcaemic and there were no major complications. Mean hospital stay was 7-days.

CONCLUSION

Focused parathyroidectomy for single gland disease and total parathyroidectomy with forearm auto-transplantation for hyperplasia was a satisfactory treatment for patients in this series.

Investigation of DAZ and RBMY1 gene expression in human testis by quantitative real-time PCR

This study developed quantitative real-time PCR assays for the DAZ and RBMY1 genes to determine the copy number of RNA extracted from testicular biopsies from a cohort of normospermic controls (n=6) and azoospermic males (n=17) including two males with Y-chromosome microdeletions (AZFc and AZFb + c). All patients underwent testicular sperm extraction (TESE) for intracytoplasmic sperm injection (ICSI). Forty percent of the azoospermic cohort showed a significant reduction in the copies of at least one of the genes (DAZ P=0.003; RBMY1 P=0.009). The histopathology of these patients ranged from Sertoli cell only (SCO) to severe hypospermatogenesis with interstitial fibrosis. The patient with the AZFb + c deletion lacked expression of DAZ and RBMY1 and had a histopathology of SCO. The patient with the AZFc deletion had reduced expression of RBMY1 and no DAZ expression with a histopathology of spermatocyte arrest. The quantitative real-time PCR assays for DAZ and RBMY1 gave positive predictive values of 78% and 70%, respectively for the recovery of sperm from testicular biopsy.

[Bilateral primary pseudotumoral palpebral amyloidosis. A case report]

Ocular amyloidosis is infrequent, and the palpebral location is uncommon. It usually has a primary localized form, but can occur in systemic or familial amyloidosis. The diagnosis is mainly made by histopathology. Its treatment is surgical and the prognosis depends on clinical presentation and recurrences. We report the case of a 54-year-old woman with no medical history of the disease, who had bilateral isolated palpebral amyloidosis presenting as bilateral upper lid swelling with ptosis and corneal dystrophy. Diagnosis was confirmed by palpebral biopsy and the patient underwent excision of the involved lid tissue with reconstruction of the affected lid with cartilage autograft. Clinical progression showed improvement of the ptosis and the patient's comfort. Although rare, palpebral amyloidosis poses management problems, particularly in advanced cases, because of corneal complications and recurrence.

Ileosigmoid knotting

Ileosigmoid knotting or compound volvulus is a very uncommon cause of intestinal obstruction, which is associated with significant morbidity and mortality. A case of compound volvulus is reported in a 24 years old male patient who presented with diagnostic dilemma.

Early complications following pancreatico-duodenectomy

OBJECTIVE

To determine the mortality and morbidity in patients after Whipple's pancreaticoduodenectomy.

DESIGN

Descriptive study.

PLACE AND DURATION OF STUDY

Department of General Surgery (Ward-2), Jinnah Postgraduate Medical Centre, Karachi.

PATIENTS AND METHODS

All the patients who underwent standard Whipple's procedure were followed up during their hospital stay for early postoperative complication. The indicators for the development of complications included daily nasogastric (NG) tube output for delayed gastric emptying, ultrasound abdomen for intra-abdominal collections, presence of blood in drains and NG tubes for haemorrhage and measuring serum amylase for pancreatitis.

RESULTS

Out of 30 patients, 3 patients died in early postoperative period with 10% mortality while 26.67% had wound infection, 16.67% had chest complications, 13.34% developed intra-abdominal collections, 10% had haemorrhage, 3.34% had delayed gastric emptying, 3.34% had pancreatic fistula and 3.34% had organ failure.

CONCLUSION

In this series the procedure was associated with decreased mortality due to increased experience and skills but morbidity was still high due to lack of facilities for the detection and management of postoperative complications. It should only be performed in tertiary care centres with expert surgical teams and facilities for adequate management of postoperative complications.

CAG repeat length in an infertile male population of Irish origin

The androgen receptor (AR) gene, located on the X chromosome, is an important regulator of human spermatogenesis. In the past decade, the link between the CAG polyglutamine tract, situated on exon one of the AR gene, and reduced spermatogenesis has become a controversial one. Alterations in the length of the CAG polyglutamine tract have been associated with prostate cancer at a reduced intrinsic length and neuromuscular diseases at a CAG repeat length of > or = 40. Minimal intermediate increases have been linked with depressed spermatogenesis in infertile males. Asian and Australian groups have published an association between increased CAG repeat length and reduced spermatogenesis while many European studies have found no such association. The aim of this study was to document the association between increased CAG repeat length and reduced spermatogenesis in a group of Irish infertile males and controls known to have fathered at least one child. The study employed the ABI 377 DNA sequencer to size the CAG repeat region of exon one of the AR gene in each group. Statistical analysis revealed no actual link between the length of the CAG tract and a reduction of spermatogenesis in a cohort of infertile patients (n = 66) of Irish ethnic origin when compared to a fertile control group (n = 77) (p = 0.599).

[Synovial sarcoma of the head and neck: two cases report]

Synovial sarcomas are soft tissue tumors that rarely occur in the head and neck The purpose of this report is to accrue data on this sarcoma at a rare site, and to highlight the histopathological differential diagnosis with other cervical tumors.

MATERIALS AND METHODS

Two cases of cervico-facial tumors were reported in 26 and 27 year old women.

RESULTS

Histologically, these tumors were classified into monophasic and biphasic variants. Immunohistochemistry plays a major part in the differential diagnosis, enabling the demonstration of epithelial differentiation. Radical surgery was the mainstay of treatment with post-operative radiotherapy for residual disease in one case. Local recurrence was developed in the patient who had only surgical treatment.

DISCUSSION

Synovial sarcomas are a rare soft tissue malignancies and the head and neck region location accounts for 3-5% of them. The rarity of this tumor in the head and neck and its multitude of his histopathologic features are responsible for frequent initial misdiagnosis. Histologic, immunohistochemic and characteristic chromosomal translocation findings are necessary for diagnosis. The poor prognosis of this sarcoma justified a radical surgery with post-operative radiotherapy.

Does multidetector-row CT eliminate the role of diagnostic laparoscopy in assessing the resectability of pancreatic head adenocarcinoma?

BACKGROUND

We hypothesized that the high-quality images from multidetector-row computed tomography (MDCT) would lead to improved sensitivity and specificity for predicting resectable pancreatic head adenocarcinoma, thus diminishing the value of staging laparoscopy.

METHODS

Forty four consecutive patients underwent thin-section dual-phase MDCT to stage their tumor, followed by an attempted pancreaticoduodenectomy. Four radiologists who were blinded to the operative outcome reviewed the scans and graded the presence of distant and nodal metastases, as well as the degree of arterial and portal involvement. The radiologic criteria for resectability were no distant metastasis, a patent portal vein, and < 50% arterial involvement.

RESULTS

The overall resectability for this cohort was 52% (23/44). The 21 unresectable cases, included five liver metastases, three peritoneal metastases, and 13 locally invasive tumors. The negative margin resection rate was 34% (15/44). There were no portal vein resections. The sensitivity and specificity of MDCT for predicting resectability were 96% (22/23) and 33% (7/21), respectively. In this cohort, the positive and negative predictive values were 61% (22/36) and 87.5% (7/8), respectively. As determined by univariate logistic regression, only the degree of arterial involvement was a significant predictor of resectability (p = 0.02). As determined by multivariate logistic regression using both arterial and portal involvement, arterial involvement was predictive (p = 0.03) but portal vein involvement was not (p = 0.45).

CONCLUSIONS

Despite the improvements in image quality obtained with multidetector-row technology, CT imaging remains a relatively nonspecific test for predicting resectability in patients with adenocarcinoma of the head of the pancreas. Minimally invasive modalities with higher specificity, particularly laparoscopy, continue to have an important role in staging pancreatic head adenocarcinoma.