Laparoscopic extralevator abdominoperineal resection for low rectal cancer: The myth of reinventing the wheel

Background & Objective

To review oncological outcomes of laparoscopic extralevator abdominoperineal excision (LAP-ELAPE) for low rectal cancer.In locally advanced low rectal cancer, ELAPE which is en-bloc resection of levator muscles along with the tumor in a prone position has significantly decreased the rate of having either positive circumferential resection margin (CRM) or tumor perforation. The aim of the study was to determine the oncological outcomes of laparoscopic extralevator abdominoperineal excision (LAP-ELAPE) for low rectal cancer.

Methods

This retrospective study was performed at Shaukat Khanum Cancer Hospital and Research Centre Lahore. Patients who underwent ELAPE for low rectal and anal cancer from January 2014 to December 2019 were selected. Data was collected using an electronic database through a hospital information system.

Results

A total of 82 patients were included in the study having a median age of 39 years. Clinically preoperative tumor sizes were T2:2, T3:65, T4:15. Neo-adjuvant chemo radiotherapy was administered to 79 (96.3%) patients. Pathologically tumor sizes were T0:12, T2:15, T3:50, T4:5 with 79.2% (n=65) R0 resections. The mean operative time was 340.36±64.51 minutes and the mean blood loss was 99 milliliters. The mean postoperative hospital stay was 6.58±4.64 days. Seventeen (20.7%) cases had pathological circumferential resection margins positive (pCRM<1mm). However, tumor perforation was found in 8(9.8%) patients. Ninety days mortality was none while 36 patients experienced recurrence (local: 23, distant: 30, local + distant 17). The median survival time was 53.00±2.69 months.

Conclusion

For locally advanced low rectal cancer, ELAPE has evolved as a safe oncological procedure with acceptable outcomes.

The mystery of post-cholecystectomy persistent bile leak: a case report

Laparoscopic cholecystectomy (LC) is commonly performed for benign gallbladder diseases. Biliary leak is the most common complication of bile duct injury following this surgery. We report a case of persistent bile leak following the procedure despite endoscopic and radiological management. A female patient presented to the hepatopancreatobiliary unit of the Bahria International Hospital (Orchard), Lahore, with complaint of persistent bile leakage after laparoscopic cholecystectomy performed elsewhere. She had been investigated in various hospitals but the cause of the persistent bile leak remained a mystery and she was offered surgery. After real time fluoroscopic contrast enhanced imaging, further confirmed by a Computerised Tomography (CT) Scan of the abdomen, it was revealed that the persistent bile leak in the drain was due to iatrogenic injury of the duodenum secondary to percutaneous catheter insertion. The patient was managed non-surgically. She remained stable. This is a rare complication of one of the most common surgical procedures performed in the world.

Emergency esophagectomy: Experience of a high volume esophageal cancer center

Objective

The objective of the study was to review the experience of dealing oncological emergency esophagectomies at a dedicated Cancer hospital.

Methods

We performed a retrospective review of data of eleven esophagectomies at the Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore (SKMCH&RC) Pakistan, from 1st January, 2009 to 30th June, 2019. Out of 590 oncological esophagectomies, eleven patients had emergency resection. We collected the data of demographics, primary disease, comorbidities, location of tumor and perforation, cause of perforations, radiological and endoscopic findings, clinical findings and follow-up visits after discharge. Data was analyzed by SPSS version 21 for windows.

Result

All 11 patients out of five hunded ninety had esophageal cancer. At the time of initial staging, eight (72%) had locally advanced stage (stage III and IV). Open transhiatal approach was used in six (55%) patients, and the rest had three stage esophagectomies. Primary reconstructions with gastric conduit were performed in all, except in two (18%) patients, Respiratory complications were the most common of the encountered complications, seven (63%) of the patients had palliative resection. Ninety day mortality was observed in 3(27.3%) patients. On long term follow up, six patients had recurrence, with median Disease-Free Survival (DFS) 5.88 months and Median Overall Survival (OS) was 6.37 months. Out of 11, only three patients are alive without disease, while one patient is lost during follow-up.

Conclusion

Emergency esophagectomy is a lifesaving procedure; there should be multidisciplinary team approach towards the management. Early diagnosis and management is of paramount importance.

The mystery of post-cholecystectomy persistent bile leak: a case report

Laparoscopic cholecystectomy (LC) is commonly performed for benign gallbladder diseases. Biliary leak is the most common complication of bile duct injury following this surgery. We report a case of persistent bile leak following the procedure despite endoscopic and radiological management. A female patient presented to the hepatopancreatobiliary unit of the Bahria International Hospital (Orchard), Lahore, with complaint of persistent bile leakage after laparoscopic cholecystectomy performed elsewhere. She had been investigated in various hospitals but the cause of the persistent bile leak remained a mystery and she was offered surgery. After real time fluoroscopic contrast enhanced imaging, further confirmed by a Computerised Tomography (CT) Scan of the abdomen, it was revealed that the persistent bile leak in the drain was due to iatrogenic injury of the duodenum secondary to percutaneous catheter insertion. The patient was managed non-surgically. ---Continue

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Differentiated Thyroid Carcinoma: Distant Metastasis as an Unusual Sole Initial Manifestation

Objective:

The objective of this study was to identify the characteristic features of patients with distant metastasis as the only manifestation of well-differentiated thyroid cancers and to analyze the treatment outcomes

Methods:

A retrospective review of all patients with well-differentiated thyroid cancers and distant metastasis as the sole initial presentation was carried out. Data regarding age, gender, tumor histology, site, symptoms, and treatment outcomes were collected.

Results:

There were 10 patients who presented with distant metastasis as the only presentation. The mean age was 56.1 years. Eight (80%) patients had osseous metastasis, one (10%) had pulmonary and one (10%) had both. Follicular thyroid carcinoma was more common and seen in six (60%) patients. Seven (77.8%) out of nine patients had demised within five years of initial presentation.

Conclusion:

Distant metastases without a neck lump as the initial presentation of well-differentiated thyroid cancers are extremely rare. No specific guidelines are available to manage such patients due to lack of relevant data in the literature.

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.

Laparoscopy Offers Better Clinical Outcomes and Long-term Survival in Patients With Right Colon Cancer: Experience From National Cancer Center

Purpose

Laparoscopic approach to colonic tumor requires skill set and resources to be established as routine standard of care in most centers around the world. It presents particular challenge in country like Pakistan due to economic constrain and lack of teaching and training opportunities available for surgeons to be trained to deliver such service. The aim of this study is to look into changing practice of our institution from conventional approach of open to laparoscopic surgery for right colon cancer.

Methods

Consecutive patients between January 2010 to December 2018 who presented to Shaukat Khanum Memorial Cancer Hospital and Research Centre with diagnosis of right colon (cecum, ascending and transverse colon) adenocarcinoma and underwent surgical resections were included in this study.

Results

A total of 230 patients with adenocarcinoma of the right colon underwent curative resections during the study period. Of these, 141 patients (61.3%) underwent laparoscopic surgery while open resection was performed in 89 patients (38.7%). Five-year disease-free survival (DFS) of patients with American Joint Committee on Cancer (AJCC) stage III (80.9% vs. 54.8%, P = 0.021) was significantly better if these patients underwent laparoscopic surgery while a trend toward better DFS (96.7% vs. 84.1%, P = 0.111) was also observed in AJCC stage II patients, although this difference was not significant.

Conclusion

This study demonstrates the adoption of a laparoscopic approach for right colon cancer over 10 years. With a standardized approach and using the principle of oncological surgery, we incorporated this in our minimally invasive surgery practice at our institution.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Pancreaticogastrostomy: A Safe Option in Pancreaticoduodenectomy for Pancreatic Head and Periampullary Neoplasms

OBJECTIVE

To determine the safety of pancreaticogastrostomy in pancreaticoduodenectomy in patients with periampullary and pancreatic head neoplasms in terms of surgical technique, pancreatic fistula rate, 30 days mortality and three years survival.

STUDY DESIGN

Cohort study.

PLACE AND DURATION OF STUDY

Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, from October 2014 to September 2017.

METHODOLOGY

Patients undergoing pancreaticoduodenectomy for pancreatic head and periampullary tumors were included. Patients having metastatic disease or involvement of celiac artery, hepatic artery or superior mesenteric artery on preoperative scans, complete encasement of portal vein and superior mesenteric vein (SMV) were excluded. Patients' characteristics including the demographics, surgical technique, postoperative pancreatic fistula, 30 days mortality and three years survival were recorded. Mean ± standard deviation was used for continuous variables while frequencies and percentages were used for categorical variables. Kaplan-Meier method was used to estimate survival as a function of time, and survival differences were analysed by either Log-Rank test or Tarone-Ware test. Statistical significance was defined as a two-tailed p-value 0.05.

RESULTS

One hundred and one patients underwent pancreaticoduodenectomy. Fifty-eight (57.4%) were males and 43 (42.4%) were females (n=43). Mean age was 51.5 ±14.17 years. The commonly found tumor was periampullary adenocarcinoma which was present in 49.5% (n=50) patients followed by pancreatic head adenocarcinoma which was present in 32.7% (n=33) patients and 17.8% (n=18) patients had other tumors. Most common pathological T-stage was T3 present in 47.5% (n=48) patients, followed by T2 found in 36.6% (n=37) patients and T1 stage was present in 15.8% (n=16) patients. 57.4% (n=58) patients had node positive disease. Pancreaticogastrostomy was done in 87.13% (n=88) patients, while pancreaticojejunostomy was done in 12.87% (n=13) patients. Recurrent disease was noticed in 11.9% (n=12) patients. Mean survival of pancreatic head adenocarcinoma was 787.04 ±81.89 days, which was comparatively less than periampullary adenocarcinoma, i.e. 983.10 ±52.27 days (p=0.08). Overall mean survival was 924 ±41.3 days.

CONCLUSION

Patients with periampullary tumors had a better outcome than pancreatic head tumors in this series. Pancreaticogastrostomy can be a safe alternative to pancreaticojejunostomy, especially in patients having non-dilated pancreatic duct and soft pancreas.

Clinico-pathological Characteristics of Cutaneous Malignant Melanoma in Pakistan

OBJECTIVE

To analyse epidemiological and clinical characteristics of patients presenting with cutaneous malignant melanoma (CMM) in Pakistan; and to compare the results with other studies.

STUDY DESIGN

Case series.

PLACE AND DURATION OF STUDY

Shaukat Khaum Memorial Cancer Hospital (SKMCH) from January 1997 to December 2017.

METHODOLOGY

All patients presenting to the study centre with a diagnosis of CMM were included in the study. Non-cutaneous melanoma cases were excluded. Patient demographics, tumor type, and tumor stage were recorded retrospectively. All data were analysed in SPSS and descriptive statistics were determined.

RESULTS

A total of 169 CMM patients were registered during a 20-year period. The highest incidence of melanoma was seen in the age group 40-59 years (n=69, 40.8%). Most common clinical subtype was unspecified melanoma (n=154, 91%). The most frequently observed T-stage at presentation was Tx (n=124, 73.4%), followed by T4 (n=23, 13.6%). With regard to body distribution, CM was seen most commonly in the lower limb including hip.

CONCLUSION

CMM is a rare disease in Pakistan. However, patients tend to present at a more advanced stage. Identification of risk factors and tumor characteristics is, therefore, of paramount importance in managing these patients. Key Words: Cutaneous malignant melanoma (CMM), Pakistan, Lower middle income country, Stage.

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.

Clinicopathological Characteristics and Short-Term Survival Analyses of Cutaneous Malignant Melanoma

Objective

Cutaneous malignant melanoma (CMM) arises from melanocytes, which are pigment-producing cells in the skin. CMM constitutes less than 5% of all cutaneous malignancies worldwide but is associated with the highest mortality rate among all skin cancers. The objective of this study was to examine the profile of clinicopathological factors, survival analyses, recurrence rate, metastatic rates, and the management of CMM at Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC) in Lahore, Pakistan.

Methodology

All patients with a diagnosis of CMM treated at our institute from 2014 to 2017 were included in the study. Demographic variables and clinicopathological characteristics were collected and short-term oncological outcomes were recorded. All data were entered and analyzed in SPSS Statistics version 21 (IBM, Armonk, NY).

Results

A total of 28 patients were included in the study. The median age of the patients was 46.5 ±15.9 years. There were 16 male and 12 female patients. A family history of melanoma was present in 7.1% (n=2) of the patients. All patients had a mean survival of 13.43 ±9.09 months. The lower limb was the most common site of tumor among all patients, accounting for 46.4% (n=13) of the cases. On histopathological analyses, ulceration was seen in 53.6% (n=15) of the patients. Unclassified tumor type was present in 75% (n=21) of the patients, followed by nodular in 21.4% (n=6), and superficial spreading in 3.5% (n=1). Clark level IV was the most common presentation, constituting 46.4% (n=13) of the cases. Metastasis was seen in 50% (n=14) of the patients. Local recurrence was observed in 60.7% (n=17) of the patients; 64.3% (n=18) of the patients were alive after one year of treatment.

Conclusion

CMM is a disease with very high fatality rates. Although it is a disease commonly associated with fair-skinned populations, the incidence of CMM is rising in our part of the world as well. Early diagnosis and prompt management of the disease are crucial in its treatment. However, the mortality rate associated with this disease is still not favorable.

Laparoscopic Curative Resection for Right-Sided Colonic Tumors: Initial Experience From a Specialized Cancer Hospital of a Developing Country

Introduction

Laparoscopic colonic resection is increasingly becoming popular worldwide and aims to provide curative resection in addition to the inherent benefits of laparoscopic surgery. The aim of this study was to evaluate the long-term outcomes of laparoscopic right hemicolectomy in a Pakistani cohort of patients.

Methods and procedures

We retrospectively analyzed the medical records of all patients who presented to our hospital with the diagnosis of right-sided colon carcinoma from January 2010 to December 2018 and underwent laparoscopic right or extended right hemicolectomy. Demographics, operative findings, histopathology report, and follow-up of patients were recorded and the analysis was performed on Statistical Packages for the Social Sciences (SPSS) Version 20 (IBM Corp, Armonk, NY).

Results

Seventy-five patients were included, 56 (74.7%) of whom were males and 19 (25.3%) were females. The median age was 52 years (range 25-82 years). The median hospital stay was five days (Range 3-13 days). The median blood loss was 70 milliliters and the mean operative time was 195.5±77.6 minutes. Laparoscopic extended right hemicolectomy was performed in 23 (16.67%) patients and standard right hemicolectomy in 52 (83.33%) patients. Most (72%) of the patients had a pathological T3 tumor, and the majority (61.3%) of the patients had no nodal involvement (pN0). The mean number of lymph nodes removed was 20+8. The median numbers of involved lymph nodes were 1.14+2.19. All the patients had R0 resection. Postoperatively, two patients had pelvic collection, and there was no 30-day mortality. Local recurrence occurred in four patients and distant metastases were observed in nine patients. The median follow-up in our study was 40.5±18.35 months. The median disease-free survival was 42±2.17 months and the median overall survival was 44±2.16 months.

Conclusion

Our experience with laparoscopic right colon resections has confirmed the safety and feasibility of the procedure.

Synchronous Primary Endometrial and Ovarian Cancers: Trends and Outcomes of the Rare Disease at a South Asian Tertiary Care Cancer Center

Background and objective

The incidence of synchronous primary endometrial and ovarian cancer is uncommon and poses a diagnostic challenge to the treating physician about their origin as either primary or metastasis. The purpose of this study was to evaluate the clinicopathological behavior, treatment modality-related outcomes, and prognosis related to primary endometrial and ovarian cancers at a tertiary care referral center in South Asia.

Methods

We retrospectively analyzed 30 patients with synchronous ovarian and endometrial cancers treated at Shaukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, Pakistan from January 2005 to August 2017.

Results

The median age of the patients at the time of diagnosis was 51 years (range: 25-72 years). The common presenting symptoms were irregular uterine bleeding (30%), post-menopausal bleeding (26.7%), abdominal mass (16.7%), and abdominal pain (26.7%). Endometrial adenocarcinoma type was the most common histological variant found among the participants: 90% (n=27) of uterine and 56.7% (n=17) of ovarian cancers. All patients underwent surgical intervention. Among them, 25 patients received platinum-based adjuvant chemotherapy, four received neoadjuvant chemotherapy, and 18 received adjuvant radiotherapy. The early-stage group [International Federation of Gynecology and Obstetrics (FIGO) stage I and II] had a more favorable prognosis than the advanced stage group (FIGO stages III and IV).

Conclusion

Based on our findings, patients with synchronous primary endometrial and ovarian cancers have better overall survival rates than patients with single primary ovarian or endometrial cancers. Also, synchronous primary endometrial and ovarian cancer endometroid types have better overall survival than patients with non-endometrioid or mixed histologic types.

Malignant Melanoma of the Female Genital Tract: Experience of an Oncology Center in Pakistan

Introduction

Malignant melanoma, which arises from melanocytes or pigment cells, is one of the most common forms of epithelial cancer. Cutaneous and noncutaneous melanomas differ clinically and genetically. Mucosal melanomas are rare. In the female genital tract, the most frequent location of melanoma is the vulva, whereas the vagina is seldom affected. The occult nature of their anatomical location contributes to the late presentation and late diagnosis of vaginal melanoma, resulting in an exceedingly poor patient prognosis. The present study describes the incidence, symptoms, management, and prognosis of women in Pakistan with malignant melanoma of the vulva, vagina, and cervix.

Materials and methods

The Hospital Information System of Shaukat Khanam Memorial Cancer Hospital and Research Center was searched electronically to identify patients diagnosed with malignant melanoma from January 1995 to December 2017. Patients with cutaneous malignant melanoma, multiple primary tumors, and metastases to the female genital tract from primary tumors located elsewhere were excluded. All included patients had been diagnosed with primary malignant melanoma of the female genital tract.

Results

The search of medical records identified 271 patients with malignant melanoma, of whom 13 had primary malignant melanomas of the female genital tract. Of these 13 patients, nine, three, and one had primary vaginal, vulvar, and cervical melanomas, respectively. Median age at presentation was 60 years (range, 30-70 years), with 10 patients being post-menopausal. The most common presentations were per-vaginal bleeding and per-vaginal discharge (five patients each). The mean duration of symptoms was 7.46 months. Seven patients underwent wide local excision. Six patients had nodular type malignant melanoma, two had superficial spreading type, and five were unclassified. Nine patients had pathological T4 disease, and two had pathological T3. Mean Breslow depth was 5.4 millimeters (mm), with 10 patients having tumor depth >4 mm. Eight patients were positive for the microscopic involvement of margins. The mean time to recurrence was 11.8 months (range, 1-24 months), and the mean time to metastasis was 17.6 months (range, 2-44 months). The median survival after surgery was 25 months (range, 2-75 months).

Conclusion

This study is the first to report the incidence, symptoms, management, and prognosis of patients in Pakistan with malignant melanoma of the female genital tract. Meta-analyses and prospective multicenter studies are needed.

Benefits of Outcomes of the Microscopic Examination of Anastomotic Donuts After Colorectal Resection for Oncological Purposes: A Medical Record-Based Study

Objective 

The objective of the study is to investigate the benefits of pathological assessment of donuts removed during coloanal anastomosis after anterior resection.

Methodology

During three years, 220 patients underwent circular stapled anastomosis. It is a retrospective study with convenient sampling. Involvement of donuts, the involvement of margins, length of donuts, and margins were primarily recorded. Ethical review approval was taken from the Institutional Review Board. Hospital electronic system was used to retrieve the data.

Results

Two hundred and twenty patients underwent circular end to end anastomosis (CEEA) stapled gun anastomosis. All had adenocarcinoma. Most of the patients had T3 disease (n=113). Low anterior resection was the most common procedure followed by anterior resection and sigmoid colectomy, respectively. We performed all rectal cancers anastomosis with a circular stapling gun. On histological analyses among 220 patients, only two patients were found to have a positive distal donut. No proximal donuts were positive. Both patients were also found to have positive distal margins. The mean length of the proximal donut was 1.79±0.45 cm. The mean length of the distal donut was 1.68±0.48 cm. Two distal margins and none of the proximal margins were positive for cancer. The mean length of the proximal margin was 8.69±4.48 cm. The mean length of the distal margin was 4.9±5.98 cm. Both patients had already received six months of pre-operative chemoradiotherapy and were not offered any additional treatment. Both patients were kept on close surveillance.

Conclusion

Routine analyses of the donuts after anterior resection has no impact on the management and outcome of the disease.

Lack of awareness among surgeons regarding safe use of electrosurgery. A cross sectional survey of surgeons in Pakistan

Objective

To assess our surgeons perceptive regarding the safe usage of electrosurgical devices.

Method

ology: This cross sectional survey was carried out at two hospitals, A cancer hospital and a public sector general hospital. Consultants, fellows and senior residents (Resident year 3rd and year 4th) on the surgical floor were requested to fill up the questionnaire. Calculations were performed with Statistical Package for the Social Sciences (SPSS 20) for Windows version 20 statistical software. Data was described using median with minimum and maximum value for quantitative variables. For categorical variables, number of observations and percentages were reported. The study is complied with hospital guidelines on research involving human subjects.

Results

Out of 80 questionnaires 52 were filled and returned. 12 consultants, 16 fellows/Senior registrars and 24 senior residents filled their questionnaires. For the sake of anonymity no information was obtained regarding the level of training and experience. Total 12 questions were asked. An expert level was set for a score above 10/12. A moderate level was set at 8/12. A score of less than 8 was considered unsafe for using electrosurgical devices. Only 6 (11.5%) participants had an expert level of understanding. 16 (30.7%) had moderate understanding. 30 (57.7%) were considered unsafe regarding use of electrosurgical devices. 85% participants were not aware of the correct mode of current to use for coagulating vessels. 69% of surgeons would use electrocautery to control staple line bleeds. 67% participants weren't aware of the correct placement of dispersive electrode. 60% couldn't identify a safe device for use in patients with a pacemaker. 46% of surgeons would cut a dispersive electrode to fit it on a child. 69% believed that harmonic scalpel was a bipolar cautery. 61% couldn't differentiate between RFA and Microwave Ablation. 63% didn't know how to handle an operating room fire.

Conclusion

In these two hospitals, high level of ignorance noticed regarding the procedure and indications of basic electrosurgical equipment which needs raising awareness and further training.

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The first study to show the lack of understanding of electrosurgical devices among surgeons in Pakistan.

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Study was performed in 2 hospitals and included consultants, fellows and residents

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A survey was distributed and questions pertinent to the use of electrosurgical devices were asked.

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Surgical residents, fellows and consultants were equally unaware of how these devices work.

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Study highlights the need to start training courses for these devices.

Risk Factors For Chyle Leak After Esophagectomy

BACKGROUND

Chylothorax is an uncommon (3-8% risk) but potentially fatal complication of esophagectomy with poorly understood risk factors. It has a high morbidity due to loss of fluids, electrolytes, and other nutrients, loss of lymphocytes and immune dysfunction.

METHODS

Retrospective chart review of adult patients who underwent esophagectomy between 2009 and 2016 was performed. Cases with chyle leak were identified according to a set criteria. Clinical features, operative findings and postoperative variables were recorded and predictors of chyle leak were analyzed.

RESULTS

During the study period, a total of 193 adult patients underwent esophagectomy of which 186 received neo adjuvant chemotherapy. The mean age was 53 years with 118 males and 74 females. Type of procedure performed was 3-stage esophagectomy in 98, Transhiatal esophagectomy in 79 and Ivor-Lewis esophagectomy in 15 patients. Chyle leak was identified in 9 (4.6%) patients. There was no significant association of chyle leak with age, gender, co-morbid, level of tumor, Neoadjuvant therapy and Type of esophagectomy. Chest drain output on postoperative day 5 was significantly predictive of chyle leak (p-value<0.05). Drain output more than 1000 on day 4 was highly suggestive of chyle leak (p-value<0.05). Day on which chest drain was removed was also found to be significantly related to chyle leak (p-value <0.05).

CONCLUSIONS

No significant preoperative risk factors were identified for chyle leak. High chest drain output on postoperative day 5 and drain output more than 1000 on day 4 are significant predictors of chyle leak.

Storage of vaccines in different health centers and pharmacies at Karachi, Pakistan: The handling errors

The fundamental human desire is prevention from the infectious disease. Vaccine is the basic element to fulfill this human craving. The proper handling of vaccine can minimize the degradation. The main aim of this study is to find out the knowledge of respondents and storage condition and handling of marketed vaccines in different private clinics, hospitals and community pharmacies in Karachi, Pakistan. The present study revealed that ~77% have been allowed to visit their vaccine storage compartment. The cumulative knowledge of respondents regarding recommended temperature, shake test, thermal, freezing and photo degradation were 49.34%, 24.01%, 95.78%, 54.35% and 47.23% respectively. The major mishandling like the medicines, food and drinks and even laboratory specimen have been noticed 76.3%, 61.62% and 5.35% respectively. Moreover, water filled bottles on upper, lower and door shelves and ice packs or ice trays 3.43% and 14.18%, respectively, have been found in refrigerators and freezers, respectively. No expired vaccines have been found. The major consequence, in the study has been found to be mishandling by the absence of non-professional personnel. Either doctors or pharmacist (health associated professionals) as respondents were nearly all aware about the consequences of the mishandling of vaccines and have the knowledge about the recommended temperature, thermal, photo degradation, and freezing hazards of vaccines. The world-renowned immunization authorities have strongly recommended national/local immunization programs. On the basis of the present study, it is recommended to train the staff and prepare a national guideline for the storage and handling of vaccines, and forcefully implements the law to adopt the particular guideline.

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.

In vitro bactericidal activity of cefepime and cefpirome against clinical isolates at Karachi

Antibiotics not only support to alleviate the infections but also facilitate to avert the multiplication of microbes. Due to the irrational use of antibiotics, the resistance of antibiotics has been augmented which results may increase in morbidity and mortality with the span of time. World renowned regulatory bodies like Food and Drug Administration (FDA), Center of Disease Control and Prevention (CDC), and World Health Organization (WHO) vigorously advocate the surveillance of the resistance of antibiotics. During the present study by Kirby-Bauer disk diffusion method 141 clinical isolates of Staphylococcus aureus (n=47, 33.34%), Escherichia coli (n=54, 38.3%), Proteus species (n=26, 18.4%), and Klebsiella pneumoniae (n=14, 9.92%) are evaluated against cefepime and cefpirome which comes of fourth generation cephalosporin. It has been found that cefpirome has better bactericidal activity than cefepime against E. coli and K. pneumoniae while cefepime has been possessed better antibacterial activity against S. aureus and Proteus species which were isolated from respiratory tract infections, blood stream infection, intra-abdominal and urinary tract infections, and skin and soft tissue infections. K. pneumoniae, E. coli, Proteus species, and S. aureus were 34.8%, 26.3%, 11.3%, and 37.7% resistance against cefepime respectively. S. aureus, E. coli, K. pneumoniae, Proteus species has shown 41.4%, 21.7%, 17.6%, and 8.9% resistance against cefpirome correspondingly.